ICD-10’s expanded specificity and precision holds the potential to reduce costs and improve health outcomes. To implement ICD-10, payers must use compliant information systems that can accommodate the longer field length and structure as well as update current business rules and processes. Regardless of the size of your plan, this transition will deeply affect a wide range of payer systems including claims adjudication, medical necessity processes, reimbursement policy, national coverage decisions, Medicare, Medicaid, and more.
Business Issues
Payers face multiple challenges including:
- Systems may not be able to compare historical ICD-9 data to new ICD-10 data for use in provider contracting and rate setting
- Older systems may not be able to handle the expanded character sets used in ICD-10
- Staff members will need ICD-10 training in order to develop business rules used in claims adjudication, fraud detection, medical management, medical policy, and any claims auditing efforts
- To improve clinical documentation, payers will need to provide the proper physician incentives through value-based purchasing initiatives
- Provider help lines will need additional staff to accommodate higher call volumes
- Payers may see a drop in reimbursement and lower first-pass rates for claims
- Providers running dual billing systems will likely submit claims in both ICD-9 and ICD-10 formats
- Systems will need to utilize the reimbursement mapper for all payment methodologies that currently use ICD-9-CM codes
Critical questions every executive should be asking:
- Do I trust that vendors of my critical IT systems will be ready by the ICD-10 deadline?
- Does the switchover to ICD-10 provide the cover we need to upgrade our older systems?
- Which aspects of the ICD-10 transition could I outsource?
- Do I need to reprice underwriting services?
- Do I need to negotiate new provider contracts that include new reimbursement structures?
- How can I use this transition to strengthen my provider network?
- How will medical policies change under ICD-10?
- Who should be the key players as we develop an IT implementation plan?
Why should you consider Ingenix as an ICD-10 partner?
ICD-10 represents a massive advance in scale, scope, and complexity over ICD-9, and has required multi-year implementation efforts in other countries that have adopted it. Organizations need to start preparing now.
Ingenix can help you use the transition to ICD-10 to your greatest advantage. Because we provide services to payers, hospitals, health systems networks, physicians, government agencies, and other health care stakeholders, we bring a strategic perspective unmatched by other information technology providers. Our solutions are informed by 25 years of experience in coding, payment, and reimbursement methodologies.
- Ingenix offers a full suite of comprehensive ICD-10 ready products and services
- Ingenix Consulting experts can help evaluate your legacy systems to identify whether you need to upgrade or replace
- Ingenix consultants can also conduct a full assessment of your applications and interfaces for membership, utilization review, and provider networks
- We offer underwriting and actuarial tools that combine data, analytics, and technology to help you set the most appropriate underwriting rates
- Our network solutions include advanced strategic techniques that help you assess your business processes, identify gaps, and build and maintain a strong provider network
- We provide online training programs that can help you prepare staff members for the changes this will bring
- We are uniquely qualified, providing coding and analytic tools to 70,000 healthcare organizations and 670,000 individual physicians.
- We have the necessary depth and breadth—we can expertly identify the right marriage of products and services for ICD-10 compliance depending on the need
Ingenix technology solutions will be ICD-10 compatible in advance of the deadlines to enable clients to implement, test, and optimize needed upgrades.
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