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Apr 9 2012   12:14PM GMT

ICD-10 implementation for payers: The BPM angle

Posted by: Jenny Laurello
BPM, Business process management for ICD-10, ICD-10

Guest post by: Baskar Mohan, Director, Healthcare Practice, Virtusa Corporation

The health care industry is currently looking at ways to leverage existing assets and projects to reduce time and the financial burden of ICD-10 implementation. Most health care organizations view Business Process Management (BPM) as an important strategy to help them stay competitive and attract new customers in a highly de-regulated market. In this blog, we will look at how BPM can help payers with their ICD-10 implementation.

As outlined in the five areas below, re-imbursement management is one example of where BPM can be effectively leveraged for ICD-10 implementation.

  1. Claims Submission: Claims submission applications need to be remediated for ICD-10. Some of these applications are still green screen, lack real estate and are cost prohibitive. Leveraging the rules capability of BPM will enable the rapid building of applications. This will also ensure that data is cleansed before it enters the EDI systems thereby reducing the number of rejections.
  2. Claims Adjudication: It is estimated that claims first pass rate will reduce significantly due to ICD-10 implementation. Leveraging BPM workflow and rules capabilities to build a wraparound system to monitor and automate adjudications will help manage adjudications more effectively.
  3. Claims Payment: Using BPM, coding payment rules can help provide businesses with the power to change them without going through long development cycles, thereby bringing flexibility to adapt or change as per market conditions.
  4. Fraud Detection: BPM can be used along with other data mining tools to thwart fraudulent claim submissions including un-bundling of claims and other fraud practices. Creating a more robust workflow to route suspicious claims to experienced adjudicators and reviewers will help create a good ROI for ICD-10 implementation.
  5. Pay for Performance: The recent shift has indicated that more Payers including Medicare & Medicaid are moving toward pay-for-performance. Complex rules to build these payment schedules can be built using BPM as most of them have to be re-visited for ICD-10 compliance.

Apart from the above benefits, ICD-10 implementation can be hassle free and effective when combined with BPM, a technology that will make life easier for everyone including IT and business. In my upcoming blog posts, I will focus on product development, care management, network management and risk management so stay tuned!

Please visit or email Mr. Mohan directly for more information.

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