Are you financially ready for ICD-10? Five questions to consider

Aug. 26, 2015
Srivaths Srinivasan, Senior Manager, Healthcare, Cognizant Business Consulting

Over the past several years, there has been an increased focus on streamlining the revenue cycle management (RCM) processes in provider offices to optimize revenue capture. As providers have upgraded their practice management systems (PMS) and electronic medical record (EMR) systems, they have also begun to focus on leveraging the technology capabilities within these systems to maximize revenue. In today’s complex world of lower reimbursements and movement toward risk-sharing payer plans, it is imperative to charge accurately and collect on all services provided.

The upcoming Oct. 1 ICD-10 deadline adds another level of complexity for provider organizations, forcing them to lock down their RCM processes sooner rather than later. As they prepare, healthcare organizations should be asking themselves the following questions:

1. Do we have a streamlined RCM process in place that minimizes claim rejections, thereby maximizing our revenues?

Receiving payment for claims today can be difficult; receiving payment for claims after the new ICD-10 code goes into effect may be overwhelming. This is due to the cascading effect of ICD-10 codes on services rendered and the ICD-10 remediated clearinghouse and payer adjudication systems. A streamlined RCM process typically means, on average, a claims rejection rate of 4 percent or less for provider offices, and 6 percent or less for billing services. If your rates are currently higher than these, you should evaluate your current rejections and immediately identify ways to reduce this rejection rate.

Eligibility is still the No. 1 reason for rejection in the industry, despite the availability of many solutions in the market.

2. Does my organization effectively manage the RCM reporting capabilities within our current systems/platforms?

With all the new systems in the marketplace today, it is critical that provider organizations have robust reporting tools tied to their PMS, hospital information systems, and/or EMR platforms. These tools can offer reports that provide operational insight and breakdown of reimbursements by payer. An appropriate RCM can help answer questions such as, “Are we having problems with certain payer reimbursements? Are we making repeated data-entry mistakes, causing rejected claims? Are we still primarily receiving paper-based explanations of benefits (EOBs) instead of electronic ones?”

Organizations often think they are streamlined and performing up to industry standards. Look into denial management tools for the next level in maximizing revenues and efficiently managing back-office processes and workload among your RCM staff. RCM solutions can point to over- or underpayment with automated appeal technology, greatly impacting your bottom line.

3. How is my office managing the patient collection process? Are we missing the opportunity to collect payment before the patient leaves? Are we making it easy for patients to pay?

Healthcare is one of the rare industries where a consumer does not always pay for services rendered at the point of service/delivery; it is estimated that nearly 80 percent of outstanding charges are not paid for at least a month. With the growth of high-deductible health plans and lower reimbursement from insurance companies, this scenario is changing. Providers need to adjust their internal processes to ensure they are collecting payments from their patients before they leave the office, when possible. This requires identifying the patient’s responsibility and providing a variety of payment options. To do so, provider organizations need to have the processes and procedures in place to accurately estimate the amount of patient responsibility (by reaching out electronically to the payers) before the patient leaves the office. Offices either need to be prepared to walk away from that revenue – or implement estimation tools, patient statement processes, and provider portals to maximize the patient revenue stream.

Consider implementing patient estimation tools and advanced eligibility solutions for your office. Explore a “credit card on file” process for your patients to help them agree to full payment reconciliation before the procedures are performed.

4. Do I have the necessary skill set within my organization to handle the ICD-10 transition?

ICD-10 will be a very difficult transition for many provider organizations. With the introduction of new codes, the rollout of new PMS/EMR platforms, and the different processing of claims due to the ICD-10 specificity in the payer adjudication systems, there is bound to be lost efficiency and operational chaos in the RCM arena. Additionally, there will be uncertainty as to the timeframe for the transmission and processing of claims between the clearinghouse and the payer. Providers need to have the necessary coders skilled in ICD-10, either within their organizations and/or by leveraging outsourced entities to assist with coding or billing processes. Having a plan in place now will help alleviate issues come October.

Look to other providers and provider organizations for tips to help with this process. Sometimes outsourcing this skill set is a better option than trying to train your current internal team in a short period of time. Also, after Oct. 1 there will still be a need to handle ICD-9-based claims, such as denials from payers, resubmits, etc.

5. Has our organization planned financially for a potential reduction in reimbursements due to errors in ICD-10-based adjudication by payers and rejections due to the increased specificity of ICD-10?

The industry is jumping into the deep end of the pool together in October; however, every provider organization will be left to its own devices with regards to that organization’s financial health. Don’t get caught off guard. Your reimbursements may be reduced no matter how well you prepare for this transition. Look at ways to provide a financial buffer; the office lights need to remain on!