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Feb 17 2012   7:00AM GMT

Utilization management and ICD-10: 5 key benefits for payers

Posted by: Jenny Laurello
ICD-10, Utilization management

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

The health care industry as a whole is currently focused on ICD-10 assessment and remediation strategy. Even with official word of the delay of the 2013 implementation deadline from CMS, Payers and Providers are looking at various impact areas within their organization and are seeking ways to leverage the benefits from ICD-10 implementation. In my earlier blog posts, I have talked at a high level about Utilization Management, which is part of Care Management. With the high-rising costs of health care, ICD-10 implementation could be seen as a blessing in disguise.

Let’s look at some key areas that will benefit from the ICD-10 implementation:

  1. 1. Ensure proper medical care: Utilization Management Organizations (UMO) are faced with a double-edged sword in that they need to ensure proper medical care to their members but at the same time must reduce overall health care costs associated with the suggested procedures. ICD-10 implementation will provide more granularities and help UMOs recommend the best care for their members.
  2. 2. Prior authorizations: Medical reviewers are provided with additional information that they never had before. This will enable quick turnaround times for authorizations. ICD-10 implementation will also help reduce unnecessary and sometimes harmful procedures.
  3. 3. Auto approvals: Business rules should be part of most ICD-10 implementations. ICD-10 implementations will provide much-needed information to automate most of the authorizations that were done manually due to the limitations of ICD-9 codes.
  4. 4. Claims adjudication: Due to automated prior authorizations, information regarding claim payments is available just in time for the proper adjudication and matching of claims data. Business rules automation could also enable reduced claim denials.
  5. 5. Meaningful medical policies: ICD-10 implementation provides a golden opportunity for Payers as they would have access to new Utilization data that could provide more insight into patient care and therefore enable them to create new medical policies, which will reduce abuse of medical services and focus on patient care.

Apart from the above benefits, ICD-10 implementation provides a holistic view of patient care. Payers should take advantage of this implementation and try to harvest and automate their business rules which in turn will create a more advanced Care Management System.

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

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