It’s an unfortunate truth: Fraud, waste and abuse (FWA) runs rampant across the healthcare marketplace. According to several industry sources, in 2011 more than $98 billion was lost due to Medicare and Medicaid fraud, waste and abuse alone and tens of billions of dollars more at commercial health plans. In fact, estimates suggest between three and ten percent of all U.S. dollars spent on healthcare services are attributed to this issue. With healthcare costs continuing to hamstring the nation’s economy it’s an epidemic that insurers and providers simply must get under control.
The Affordable Care Act (ACA) most certainly recognizes the importance of addressing the nation’s fraud, waste and abuse problem. In fact, this new healthcare legislation dedicates $350 million to be spent during the next 10 years to help fight the issue. In addition, the ACA includes several new rules and penalties designed to help reduce the amount of healthcare fraud happening each year. But it’s not enough. Read more
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Fraud, Waste and Abuse: What today’s leading organizations are recommending to transform unnecessary costs into a strategic opportunity
2014 is Right Around the Corner – Are you Ready?
Healthcare reform is underway. Will your organization be ready to distribute claims payments via Electronic Funds Transfer (EFT), offer electronic enrollment for EFT and comply with other EFT-related guidelines?
Emdeon recognizes the challenges you face on the path to achieving compliance by January 1, 2014. That’s where we come. Our EFT Mandate Resource Page is designed make sure you’re asking your compliance partner the right questions, helping you plan appropriately. Learn more
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Enabling the Future: Modernizing Core Administration Systems – Planning a System Implementation, an HTMS whitepaper
As a result of healthcare reform, consumer driven markets, and other industry transforming dynamics, many health plans have found they cannot support their current and future operations with their current core administrative systems. While this rapidly changing environment presents many challenges— including medical loss ratio caps and the operational and technical requirements that could be mandated for plans that participate in Health Insurance Marketplaces (HIMs)—it also creates significant opportunities. Health plans must ensure their transactional systems are robust, efficient, flexible and based on an extensible architecture.
Organizations know that replacing a core system is a significant undertaking, and most make good faith efforts to plan and prepare accordingly. Nonetheless, it’s easy to underestimate the degree to which these projects will affect all aspects of the business and the inherent risks associated with such endeavors. A core system implementation or replacement project is truly an enterprise-wide business and technology transformation initiative. Most organizations that have lived through a core system modernization agree that the effort was, in hindsight, much more challenging, expensive and time-consuming than anticipated. Read the full whitepaper
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Upcoming Emdeon Insights Payer Webinars:
1. HIPAA Regulations: Pilot Testing New Versions
CMS/OESS awarded Emdeon with a contract to explore the concept of pilot testing of new versions of HIPAA standards. Join Emdeon on Monday, November 4th, for a regulatory webinar about pilot testing new versions of ASC X12! Register today!
2. Fraud, Waste and Abuse—Transform Unnecessary Costs into Strategic Opportunities
Join us on Tuesday, October 29th, as Kelli Garvanian, payment integrity solutions consultant, and Jim McCall, director of payment integrity solutions and fraud analytics, discuss today’s biggest challenges and explore how business leaders are employing creative strategies to combat fraud, waste and abuse. Register now!
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Are you COMPLETE?
Have you heard the latest buzz? Emdeon Payer Complete is the single solution for COMPLETE claims, payments, cost containment and payment integrity. By combining Emdeon’s industry-leading EDI services, world-class payment integrity services, and the largest healthcare payment network in the industry, Emdeon Payer Complete provides one complete solution. All for less. Learn more.
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Visit Emdeon at these Upcoming Conferences
Emdeon stays on top of all the latest national health care trends by attending and participating at many industry trade shows and conferences each month. View Emdeon’s complete upcoming conference and trade show calendar at http://www.emdeon.com/tradeshows/.
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The Future of Provider Payment Optimization
Of the $2.5 trillion spent annually on health care in the United States, nearly $800 billion is attributed to wasteful and redundant practices. As the industry continues to feel the pressures of mounting costs, Medical Loss Ratio mandates, lingering economic uncertainties and complex reimbursement rules, finding efficiencies and reducing expenses remains critical. Fortunately, the current healthcare system offers many opportunities to do so, particularly within the claims reimbursement process.
To find out how some leading payers and providers are reducing expenses, download Emdeon’s newest white paper, The Future of Provider Payment Optimization, available at http://www.emdeon.com/resourcepdfs/EMDA1010391.pdf.
Emdeon Launches Emdeon EDGE™ to Help Customers Combat Fraud, Waste & Abuse
Overpayments due to Fraud, Waste & Abuse are estimated to be a staggering $700 billion a year. To help customers solve the FWA challenges, Emdeon launched Emdeon EDGE™ in October 2012. This comprehensive solution brings together four industry leaders – EquiClaim, TC3 Health, the Sentinel Group, and Emdeon – to offer an end-to-end payment integrity solution. Learn more.
Payers and Providers Talk About Accountable Care Organizations
HTMS, an Emdeon company, recently published a whitepaper that reports on the thoughts and opinions about Accountable Care Organizations (ACOs) from both health care payers and providers. The whitepaper defines the ACO model and addresses the important relationships that exist between high quality care and the efficient (and lower cost) delivery of care – a topic both payers and providers grapple with as they consider transitioning to an ACO model.
To read the whitepaper in its entirety, visit: http://www.htms.com/pdfs/HTMS1040021.pdf
Emdeon Awarded Health and Human Services Contract to Define Process for Electronic Healthcare Transaction
On February 4, the Centers for Medicare and Medicaid (CMS) awarded Emdeon a contract to define the processes and tools needed to move electronic healthcare transaction standards to a new version. The process Emdeon develops will include analytical methodology that CMS will use to estimate the industry impact of moving to a new version of electronic transaction standards.
For more details, please read the news release about the project.
Emdeon ICD-10 Update Webinar
Emdeon recently hosted an ICD-10 Update webinar for our payer clients. We want to help you be ready for ICD-10 compliance when the clock strikes in October 2014!
View the recording here
On this call we will take you step by step through:
• Readiness & Planning
• ICD Code Utilization
• Cross-Walking Position
• Clearinghouse Edits
• Trading Partner Contingency Planning
• Customer Impact
• External Testing Approach
Visit Emdeon At These Upcoming Conferences and Events
Emdeon stays on top of all the latest national health care trends by attending and participating at many industry trade shows and conferences each month. View Emdeon’s complete upcoming conference and trade show calendar at http://www.emdeon.com/tradeshows/.
Emdeon Acquires EquiClaim to Expand its Payment Integrity Solutions Offering
We are excited to announce Emdeon has acquired EquiClaim, a leading provider of post-payment healthcare claims audit and recovery services for commercial and government payers, from MultiPlan. EquiClaim’s programs enable Emdeon Payment Integrity Solutions to offer healthcare payers a more comprehensive suite of prospective and retrospective payment integrity services. EquiClaim’s offerings, now named Emdeon Audit and Recovery Services, are designed to provide credible and objective programs that help payers reimburse providers appropriately and provide a foundation for both parties to improve the payment process.
Emdeon now offers commercial and government payers:
• Robust payment integrity services with enhanced audit capabilities, enabling retrospective recoveries for improper payments
• Improved payment integrity through enhanced intelligence, for claims review in accordance with medical billing guidelines, contractual obligations and reimbursement rates and policies
• Recovery audit contractor (RAC) services, specifically for the government sector, in support of the program the Centers for Medicare and Medicaid Services (CMS) introduced in 2005 and recently rolled out to state Medicaid programs
• More tools to help reduce general and administrative costs, by improving the accuracy of the claims payment process and the recovery of improper payments
• Enriched, comprehensive payment integrity solutions that include both pre-adjudication validation (clinical code validation, provider verification, predictive and rules-based fraud detection software and analytics), as well as post-adjudication validation (special investigative unit services, post-payment audits for contract compliance, and hospital bill audit and diagnosis-related group (DRG) audit services
With this acquisition, Emdeon furthers its goal of helping payers make appropriate payments as well as working to make sure providers receive reimbursements from payers that meet negotiated, contracted rates.
How Emdeon Audit and Recovery Services Can Help with ICD-10 Transitions
CMS reports that mandated claims coding changes (from ICD-9 codes to new ICD-10 codes) will likely cost the health insurance industry more than $1 billion. CMS also anticipates an initial 10 percent increase in the number of claims rejected for improper coding.
Adding EquiClaim's capabilities to Emdeon's Payment Integrity Solutions offers Emdeon's payer customers more tools and expertise to help meet this regulatory-driven challenge. It also further positions Emdeon to help its government and commercial customers' initiatives promote cost-effective healthcare and reduce fraud, waste and abuse (FWA).
EquiClaim was one of the first subcontractors for CMS's RAC program. As mentioned above, CMS introduced the RAC program in 2005 and recently rolled it out to state Medicaid programs under Section 6411 of the Patient Protection and Affordable Care Act. The RAC program is a cost-containment effort intended to reduce improper payments within the Medicare and Medicaid programs. It also aims to identify process improvements that could reduce or eliminate future improper payments.
EquiClaim's capabilities give Emdeon more ways to help its payer customers resolve payment issues arising from increasingly complex provider contracts, reimbursement methodologies and claim payment policies. Emdeon’s end-to-end prospective and retrospective payment integrity solutions can help payers be more efficient and improve cash flow.
To discover more about Emdeon Payment Integrity Solutions, visit www.emdeon.com/paymentintegrity.
Pre-Payment Fraud Detection and its Impact on the Bottom Line: A New Payment Integrity White Paper
The phrase, “An ounce of prevention is worth a pound of cure” aptly applies to a movement within the healthcare payment industry: Fraud, waste and abuse (FWA) prevention. Because of lean budgets and compelling cost analyses, payers are motivated to find payment integrity solutions that can identify FWA before paying erroneous claims. For optimal aberrance detection, consider adopting a proactive, preventive approach.
This white paper can help payers determine the best ways to protect themselves against FWA. It demonstrates the benefits of proactive, in-stream claims review and illuminates powerful preventive resources, to understand how to limit unnecessary claim payment, potentially saving significant time and money.
Specifically, this white paper details:
•How shifting to a pre-adjudication or pre-payment fraud detection solution can yield significant financial impact
•Characteristics of an effective pre-payment FWA management solution
•Organization, system and process implications of adopting a pre-payment FWA management solution
To read this white paper or to discover more about Emdeon Payment Integrity Solutions, visit www.emdeon.com/paymentintegrity.
Industry-leading education sessions from AHIP’s Institute 2011
Emdeon hosted several speaking sessions during America’s Health Insurance Plan’s (AHIP) Institute 2011 Conference June 15-17 in San Francisco. If you weren’t one of the more than 3,000 AHIP attendees, or if you missed one of Emdeon’s six in-booth speaking sessions, you can watch these presentations online.
Emdeon’s in-booth presentations included:
•Fraud, Waste and Abuse Prevention: An Industry Perspective, presented by: Louis Saccoccio, JD, Executive Director, National Healthcare Anti-Fraud Association (NHCAA) and Kelli Garvanian, Payment Integrity Solutions Consultant, Emdeon
•How to Save $9 Million Preventing Fraud, Waste and Abuse: A HealthMarkets Case Study, presented by: Taryn Risucci, Vice President, HealthMarkets
•The Next Generation Health Plan: Intentional Transformation, presented by: David Gallegos, SVP of Consulting, HTMS, an Emdeon company,
and Nancy Wise, VP of Planning and Strategy, HTMS, an Emdeon company
To learn more about these topics or to access other Emdeon presentations, including white papers and webinars, visit www.emdeon.com/ahip2011speakers.
Simplify Your Business with Two Bigger, Faster, Better Solutions from Emdeon
Have you ever seen a duck gliding on a lake? It's a serene image: As sunlight gleams on the duck's iridescent feathers, it skims smoothly and seamlessly on the glass-like water. Yet just underneath the surface, the duck's feet paddle quickly, furiously, relentlessly—in constant, concerted effort to keep moving forward. It takes tremendous work to look that effortless.
Emdeon is much like that duck; our systems work ceaselessly, and our people are endlessly innovating, creating bigger, faster and better ways to simplify the business of healthcare. As our partner, you enjoy the smooth reliability of the more than 100 solutions Emdeon offers. You can conduct business with seamless functionality because we're paddling nonstop to save you time, money and effort managing the revenue and payment cycle.
However, at Emdeon, "bigger, faster, better" is never enough. Our goal is to give you the services and support you need to lead. We are constantly improving, working to advance our existing solutions and pinpoint new ones, to enhance your ever-growing, ever-changing business. We're pleased to report the proverbial paddling has paid off once more in the form of two major innovations: Emdeon's data center additions and our new, best-in-class print technology.
Emdeon Data Centers
We invite you to look below the surface to get a glimpse of all that goes on— not only to maintain the single largest financial and administrative information exchange in the U.S. healthcare system—but also to take it to new heights.
Our data centers deftly, reliably and securely transmit an enormous number of information exchange points and transactions at any given minute, on any given day—such is the business of healthcare. Yet the volume of data exchanged is not nearly as impressive—or important—as what we can now do with this data.
Rather than keep data chained together through separate business rules and processes, as previously required, our technology now allows us to create data mash-ups, combining and aggregating data to make information more useful and nimble.
Here's a quick look at the advanced capabilities this technology can enable.
For payers:
•Decrease call center and other operational costs by minimizing errors or omissions in provider claims
•Detect potential insurance fraud before claims payment
•Offer providers preventive patient care messages using the patient’s medical and pharmacy histories
•Eliminate pounds of paper received by mail or fax
For providers:
•Get paid faster—using electronic claims that are auto-corrected and/or enriched with eligibility data to increase auto-adjudication rates
•Receive remittance advice or payment estimates within seconds of filing an electronic claim
•Easily obtain comprehensive, accurate patient medical and prescription histories
•Monitor patients’ adherence to disease management protocols during defined periods
In bringing the new data centers online, we have streamlined many of our business processes, reducing the potential for human error. Automating these processes allows us to more accurately measure performance and anticipate issues before they become a problem. Already we have seen a steady decrease of calls at our call center and increased customer satisfaction.
Our new, massive data centers are "state-of-the-art" in every sense, exchanging data at lightning speed to eliminate downtime and increase productivity. With hundreds of miles between them, these facilities are redundant yet independent, to ensure all data is secure, safe and accessible—without interruption.
These centers feature:
•55,000 square feet, with 2,000 servers
•Two petabytes of storage (That’s 2,000 terabytes!)
•20+ load balancers (10+ redundant clusters)
•900 Microsoft Windows servers
•350 IBM AIX Unix servers
•500+ VMWare virtual guests
•450 databases
•100 percent growth potential
Unparalleled Printing Advancements
We have introduced the Pitney Bowes® IntelliJet™ 30 printing system, for the next generation in on-demand printing technology and patient communication production. As one of only three such systems in the world, Pitney Bowes IntelliJet™ takes the idea of "fast, high-quality printing" to stratospheric levels. With amazing 120x600 dpi output at 1,380 pages per minute, there is virtually no limit to what providers can create, design and produce for patient communication.
This new printing technology offers:
•Advanced print quality for razor sharp, vibrant patient statements
•Full-color, two-sided statements with exceptional resolution—1200 x 600 dpi
•Print rates of 1,380 pages per minute (400 feet of paper per minute)
With this new capability, Emdeon ExpressBill is more responsive than ever, and can produce patient statements quickly, regardless of quantity. We can also easily update the statement design and content and print statements on demand—eliminating costs and waste associated with traditional methods.
In addition, patient statements now enter the mail significantly sooner than before, through logical presorting that combines postal codes before printing, eliminating USPS sorting delays. Emdeon can print batched statements in full color—pre-sorting them—so statements hit the mail immediately upon completion. Statements mailed sooner often lead to faster payment.
At Emdeon, we know we are doing our job when you see "the duck gliding across the water" and you don’t have to worry what’s required to keep things moving. With these exciting changes, Emdeon has made it possible for you to go about your business more easily, while we keep "paddling" to our next innovative solution.
To discover more about Emdeon’s innovations and for a video tour, please visit www.emdeon.com/innovation.
HIPAA Simplified Update
We are pleased to announce Emdeon has met requirements of the Electronic Healthcare Network Accreditation Commission's 5010 Readiness Assessment Program. Emdeon scored 100 percent, further demonstrating our ongoing commitment to help ensure HIPAA 5010 compliance.
In addition to this recognition, Emdeon continues to help our payer partners and submitters successfully migrate to the X12 5010 and NCPDP D.0 versions of HIPAA transaction standards. We have updated our gap analysis documents to include the recent 5010 Errata changes and have enhanced our 5010 systems and products to support these changes. Errata versions of the gap analysis documents are available at the HIPAA Simplified website under 'Downloads'.
We strive to provide updated and accurate information for HIPAA 5010 readiness. Answers to the most commonly asked questions about HIPAA 5010 are below.
Q. How is Emdeon preparing for HIPAA 5010 testing?
A. Emdeon is testing and implementing 5010 standards with submitters and payers. The late release of the Errata changes to the 5010 transaction standards further constricted the already narrow 5010 testing and conversion window. Nevertheless, Emdeon has initiated submitter and payer testing on all 5010 transactions, as you can see in the list below.
Q. Which Errata tests are being conducted?
A.
•837 Professional claims
•837 Institutional claims
•837 Dental claims
•835 ERAs
•270/271 Eligibility verification
Emdeon is also testing with submitters and payers the Final Rule version for HIPAA X12 transactions the Errata revisions did not include:
•276/277 Claim Status
•278 Referral/Authorization
Emdeon's guiding principles for the 5010 program are to sponsor a rational, orderly and realistic transition while protecting provider cash flow and successful payer EDI penetration.
Q. What is the timeline of events?
A. Emdeon is committed to supporting 5010 standard transactions on all of its products and services prior to the compliance date (January 1, 2012). Emdeon is in 5010 production with early implementer submitters and payers and is also in 5010 testing with many of our trading partners.
Q. Where can I find additional HIPAA 5010 information?
A. Emdeon has created a valuable resource, HIPAA Simplified, that is available to all industry stakeholders at www.hipaasimplified.com. HIPAA Simplified is a one-stop, online resource that features gap analysis, business-level documentation, webinars, transition timelines and customer testing information.
Thank you for trusting Emdeon as your information source for HIPAA readiness. We work diligently to deliver solutions that help our submitters and payers seamlessly meet industry regulations.
An Inside Look at HTMS, Emdeon's Newest Payer Solution Offering
Through the acquisition of Healthcare Technology Management Services (HTMS) in March 2010, Emdeon now offers consulting services to help payers innovate, solve problems and optimize performance in an ever-changing healthcare environment. Acting as a strategic partner, HTMS, an Emdeon Company, helps healthcare clients develop and implement technology solutions to align with healthcare trends and each client's overall business strategy. HTMS empowers payers to achieve technology-enabled transformations.
Mike Comick, HTMS co-founder, explains what makes HTMS unique and shares the company’s focus for 2011 in this question-and-answer session.
Q. How did HTMS get started and what was your vision for the company?
A. Mike Weiher and I started HTMS in 2000– each of us has more than 25 years’ experience as healthcare consultants. Through the years, we have seen demands for healthcare consulting change. In response, we wanted to create a company that offers productive, experienced staff with specific skill sets and expertise that work variable lengths of engagement to meet particular client requirements. Our strategic approach includes reality-based interventions with practical solutions and measurable outcomes.
Q. You two are healthcare veterans! How does HTMS differ from other consulting companies?
A. We reduce the risk inherent to consulting by getting the people a payer really needs to do the job. We make sure our consultants have the specific expertise a payer wants and are engaged only at certain times, when the payer needs them. This helps us keep roles competitive and minimizes excess costs.
Another thing that makes us different is our employee model. We have 80-110 people in the field…a 40/60 ratio of employees to contractors. Our consultants have deep health industry knowledge. They have experienced a lot of the challenges organizations face, so they understand that payers may have limited time and resources, out-of-date systems, antiquated processes and diverse perspectives.
Q. Targeted staffing and optimal efficiency must be especially popular with payers these days. Which successes make you especially proud?
A. We focus on healthcare technology and operations at the executive level. As numerous regulatory and market‐driven healthcare IT changes converge, payers have to assess their existing platforms and respond to these changes. HTMS specializes in researching and assessing the healthcare IT software and service vendor market for “best-of-breed” solutions. Our leadership team has a unique blend of experience, including senior executives from healthcare organizations and leading market research firms.
Key Focus Areas Include:
• Core claims and administrative systems
• Care management
• Automated member acquisition
• Healthcare reform
-5010
-ICD-10
-MLR
-Meaningful Use
-Health Benefit Exchange
Q. Those are all very important topics for payers. How do you typically engage a payer client?
A. Our goal is to determine what the client wants– to peel the onion, so to speak. We consider education and market awareness to evaluate how a particular payer compares to its peers, and establish what it would take for the payer to compete with its leading competitors. Then we assess whether the client is willing or able to commit resources– financial, system and time- or if they can procure what’s needed to reach the top in that market. Once we’ve determined that, we analyze the payer’s strategic plan and identify gaps. Afterward, we implement and execute, testing all the systems and applying industry best practices.
Q. How do you evaluate a payer’s peers?
A. Each month HTMS distributes a survey with 8-15 questions about critical issues plans face today. The responses we receive provide benchmarking information and help us assess how payers are faring in a certain area, such as ICD-10 preparedness. Once we aggregate the data, we create a summary of our findings, which we share in a knowledge brief. We send a link to these online results when we survey payers about the next month’s topic. HTMS has conducted the surveys for years and has gained valuable insight and perspective into the payer market. We look forward to expanding the surveys and building our recipient list.
Previous surveys covered topics such as:
• Program management and organizational prioritization
• ICD-10 readiness among health plans
• Health plans struggling with 5010 compliance
Q. The survey feedback sounds especially useful. But, are there privacy concerns?
A. No. Survey responses and results are shared, but no proprietary information or identifying characteristics are given. The information gleaned from these surveys is NOT used for sales, but rather to give HTMS better insight into the payer marketplace. Interested in participating in the HTMS Executive Survey program? Email research@htms.com and request to be included in our next survey.
Q. That will likely reassure our readers. How will HTMS help payers respond to recent legislative changes in healthcare?
A. In light of ongoing healthcare reform, regulatory changes and the consumerism trend, payers need help assessing their current IT strategies– now more than ever. The HTMS team provides strategic support of technical remediation, such as the transition to the new version 5010 and pharmacy D.0 transaction formats, through the delivery of education and training workshops. For example, HTMS can help clients identify the impact of changes to workflow, systems, coding and clinical guidelines they will face in the transition to new ICD-10 code sets.
Q. ICD-10 impact is at the top of many payers’ concerns. What’s one area you’re passionate about personally?
A. While my coworkers at HTMS recognize me for my healthcare expertise, I also get a lot of attention for my love of the New England Patriots. With HTMS based in Indianapolis, Indiana, home to the Indianapolis Colts, my choice of teams baffles a lot of my Colts-leaning coworkers. They do, however, enjoy debating the topic with me during football season—or just about any time!
Q. Well, that can certainly divide an office! What’s your primary focus for 2011?
A. The Patriots starting the season off strong! Oh, you mean at HTMS? The evolution of healthcare reform and its subsequent implications for payers. We’ll start by evaluating a payer’s IT portfolio management systems to determine whether their technology and/or internal systems meet new and future requirements. Then, we’ll establish remediation and system replacement and, if applicable, recommend system and organizational investments.
We plan to pay special attention to:
• Commercial plans
• Traditional Medicaid-only plans
• Specific healthcare reform issues in CA and MA
For more information about HTMS, an Emdeon company, including survey results and white papers, visit www.HTMS.com.
Michael Comick, Partner
As principal and co-founder of HTMS, Mike Comick leads HTMS' business development initiatives and industry intelligence and analytics practice while directing automated member acquisition and care management service offerings. He focuses on strategic consulting services, including IT and business planning, system assessments and procurements, and implementation services. Previously, Mr. Comick was a vice president with First Consulting Group's Los Angeles office, specializing in core claims and administration software applications. He joined FCG after working with Charles J. Singer and Co./Gartner Group as the practice leader for core system market research. In that capacity, he published the ‘Managed Care System Vendor Guides,’ the ‘Managed Care System Win/Loss Analysis’ and the ‘HMO MIS Budget Report,’ a comparative analysis of the leading managed care systems in the industry today. Using this analysis, Mr. Comick facilitated numerous workshops and education sessions with both the payer and at-risk provider markets. He has a degree in economics. When he’s not working, Mike collects and wears a lot of Hawaiian shirts—and enjoys greeting colleagues with an enthusiastic, pirate-style “Arrrrrgggghhh!”, a tradition that began at a company meeting several years ago and remains today.
ICD-10: Moving Beyond Compliance to Leading Edge Innovation
by Benjamin Heck, MHA
“This massive effort …calls for all healthcare stakeholders to completely rework operations for claims processing, provider contracting, medical management, quality reporting, information technology, disease management and other business and healthcare activities. ”
—Karen Ignani, President and CEO, AHIP www.AHIP.org
ICD-10 implementation may be one of the biggest challenges payers will face in the next five years. Though often seen as a compliance issue, ICD-10 offers a new way of doing business for those who embrace and plan for the change, instead of just responding to it. Given its wide-ranging impact on multiple payer departments and supporting technology, planning a strategic approach to imminent ICD-10 requirements is critical.
To develop this approach and gain a competitive advantage, payers must first:
• Understand ICD-10’s impact on virtually all payer information systems, operations, medical policy, staff, rules and processes
• Realize compliance is not just about programming system changes – it is about re-engineering business processes to harness the clinical detail ICD-10 provides
• Compress timelines and implement new processes quickly, to maximize the power of ICD-10 and ensure a smooth transition
• Communicate closely with provider networks to minimize negative transition effects and maintain goodwill
ICD-10 coding can offer many benefits, including:
• More accurate payment for new procedures. The American Medical Association (AMA) estimates the health insurance industry could save $777.6 million in unnecessary administrative costs by improving claims processing accuracy by just one percent. Role-specific training on the new, expanded code sets and meticulous system configuration that automates claim processing can reap a valuable return. To ensure accurate, consistent communication, payers and their provider networks should examine contracts to capitalize on the more specific codes.
• Fewer fraudulent claims. Implementation of ICD-10 code sets will not eradicate healthcare fraud. However, the specific, granular nature of these codes creates more accurate data, enabling rapid detection of questionable billing patterns and fraudulent claim submissions.
• Fewer rejected claims. Rejected claims cost both providers and health plans significant money. Incomplete documentation and duplicate claims submission cause most claims rejection. Better provider education and more accurate billing will lead to more prompt payment processing.
• Improved disease management. ICD-10 codes can help case managers better identify candidates for disease management programs, thereby improving member health by preventing or delaying serious complications.
• Better coordination of response to disease outbreaks. Through common coding and reporting, healthcare institutions can identify and respond to international disease outbreaks faster and more effectively.
Critical Deadlines:
There is no indication the government will move or relax the following dates. Wishful thinking is not a compliance strategy; strategic planning is the only way to remain competitive.
• January 1, 2012—HIPAA 5010 Compliance. Plans must be able to receive claims electronically using the X12 version 5010 and NCPDP Version D.0 standards.
• October 1, 2013—Plans must comply with ICD-10 rule sets.
Benjamin Heck, MHA
Benjamin Heck has more than 15 years of experience in the healthcare industry, providing IT and health plan operations consulting. He has led, and been involved with many successful core system implementations for a variety of healthcare payer organizations and has experience in information systems, project management, consumer-driven health, business process outsourcing (BPO), Medicare Advantage, ICD-10 and health payer operations. Prior to joining HTMS, he worked as a director of operations for several Mid-West health plans. Mr. Heck currently serves as a partner with HTMS, an Emdeon company, and leads the system assessment, procurement, implementations and ICD-10 practices.
Common Sense and Common Ground Can End Healthcare Gridlock
by Emdeon CEO George Lazenby
In 2011, our country must tackle three serious but potentially conflicting objectives to return to economic health: 1) We must decide the fate of healthcare reform; and, simultaneously, 2) shrink the federal budget deficit; and 3) reduce taxpayers’ burden.
The stakes could not be higher as the 112th Congress debates repealing or modifying the Patient Protection and Affordable Care Act of 2010. Recently, the Congressional Budget Office announced the federal budget deficit for 2011 will be at least $1.5 trillion—a deficit record no one wanted to see broken.
Against this challenging background, it is easy to assume we will be stuck in healthcare gridlock. But I believe there are common sense actions we can take today, with support from across the political spectrum, that can help lead us out of gridlock and get us back on track to being a healthier nation with a brighter economic outlook.
To learn which three steps Lazenby believes could help the U.S. healthcare industry start reversing billions in annual healthcare losses, visit: www.emdeon.com/fraudprevention, and download this article from the Bureau of National Affairs’ Health Care Fraud Report.
