Codes And Conduct: Maintaining Effective Relationships With Your Payers After The ICD-10 Transition

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i-penandpaperJust the other week, we spoke to a Western regional provider of diagnostic and outpatient services who told us that the most surprising thing about the healthcare industry’s ICD-10 transition wasn’t the coding changes themselves, but the unexpected ways in which their payers responded to the changes.

“We felt like we did everything right,” the chief financial officer told us. “We trained our staff and physicians; we prepared all our systems and technology. We just never thought to ask the payers, ‘so what are you going to change when ICD-10 hits, and how can we make sure we’re working together?’ We ended up doing some scrambling after Oct. 1.”

Had this provider been working with us on revenue cycle preparations for ICD-10, we would have definitely advised them to add “remember that ICD-10 impacts your payment partners, as well” to their preparation list.

Focusing internally probably helped ensure that everyone and every system within your organization was prepared for the ICD-10 transition. In fact, early reports after the Oct. 1 implementation indicated that most organizations were adequately prepared. But you might be operating completely in the dark about how your payers have been impacted by ICD-10, or what they may be planning to change.1

What Might Have Changed Between You and Your Payers After ICD-10?
Even if there isn’t a big coding system change, you want to be on the same page as your payers in three primary areas: clinically, economically, and administratively. Clinical alignment ensures that you and your payers agree on the same evidence-based treatment practices and determine a shared definition of “appropriate care.” When payers define “appropriate care” differently, it can cause confusion and extra work. These definitions should be in coordination with physician professional societies.

Economic alignment means that you and your payers have previously agreed to all costs and rates while administrative alignment ensures that both sides understand what constitutes a successful claim and payment.

The ICD-10 transition didn’t impact all payers equally, of course; private payers and the Centers for Medicaid and Medicare Services had different challenges and adjustments. But in the same way that ICD-10 changes your processes by allowing for much more specificity in coding, requiring more documentation from your physicians and a higher skill level from your coders or revenue cycle partner, the change also allows for more discretion in your payers’ systems.2 This means there are more chances to apply new claims edits, which should be proactively discussed, not discovered when an explanation of benefits is processed.

ICD-10 may have altered your payers’ reimbursement processes, rates of reimbursement, claims processing, benefits design, benefits policies and care coordination, to start. There may be rates or processes for specific claim types that didn’t previously exist, all of which will need to be factored into your revenue cycle.

It can be easy for providers and payers to view each other as adversaries, but—especially in the wake of ICD-10 and the increased complexity it brings—collaboration and transparency about everyone’s challenges can help providers and payers adjust their processes and, ultimately, benefit patients and the healthcare community.

After all, no one benefits if your organization continues to waste time and resources sending claims that payers reject. Furthermore, your payers don’t benefit if your organization doesn’t have enough information to provide the kind of patient care that reduces their group risk and to properly file the claims.3

Small Ways to Improve Your Payer Relationships
So how can you improve the health of your payer relationships? For smaller healthcare entities with slimmer margins and tighter revenue cycles with less room for error, even a slight increase in claims rejections can be a major setback. Taking a proactive approach to your payer relationships helps avoid surprises and makes your claims process as efficient as possible. Following the ICD-10 transition, a healthcare organization should take these steps with its payment partners:

  • Stay in touch. It seems simple, but we know how hard everyone has been working to prepare for ICD-10. An improved relationship could be as simple as reaching out to your payer and asking for a regular check-in, or an updated training session. This not only helps keep you informed, but it also shows that you’re serious about working collaboratively.
  • Find a point person. Ensure you have one person you can get ahold of at your payers’ offices if you have a question about a specific claim or a larger shift in the way they process their payments. It’s much easier to cultivate a good relationship with a single person or just a couple people in the right departments than having to start over from zero with every issue.
  • Ask them how ICD-10 is going for them. This also seems simple, but you might not know unless you ask. Find out what their challenges and successes have been, and see if there’s any way that you can streamline your side of the process to aid them. Such a gesture of goodwill not only will result in reciprocation, but it will be better for your own revenue cycle’s bottom line.
  • Share your information. Transparency between payers and providers can sometimes be little more than lip service, but take it upon yourself to share your issues and successes related to ICD-10 with your payers. Working collaboratively to solve delays or refine claims to lower rejection rates will benefit everyone.4

ICD-10 is still very new. All of us in the industry—from payers to providers to revenue lifecycle partners—are all still figuring out what life with ICD-10 looks like. Most of the early reports indicate that very little has changed between providers and payers, and that most reimbursement rates have held relatively steady, but it’s unlikely that this situation will persist forever.5

Payers are also getting used to the new system, and it’s highly likely that some of them may be planning to make changes to reimbursements in the near future, once they’re able to assess what changes are necessary. Ensuring your relationships with your payers are solid, transparent and based on working toward mutually beneficial solutions can ensure that you aren’t blindsided by any future payer actions as a result of the ICD-10 transition.

Physician Revenue Navigators is a leading healthcare revenue cycle management partner, supporting healthcare organizations in all aspects of a healthy revenue lifecycle, including coding, billing, contractual adjustments, collections, HIPAA compliance and more. Contact us to learn more about how we can assist your organization in improving your revenue cycle after ICD-10.

Show 5 footnotes

  1. “Making the Health System Work Better for Everyone: the ICD-10 Collaboration Imperative,” accessed Dec. 23, 2015, https://www.optum.com/content/dam/optum/resources/whitePapers/MakingtheHealthSystemWorkBetterforEveryoneICD10.pdf
  2. “Payer-Provider Collaboration: Strategies to test ICD-10,” accessed Dec. 23, 2015, http://www.teamiha.org/Documents/ICD10/Provider-Payer%20Collaboration%20Strategies%20to%20Test%20-%20Chris,%20Melinda,%20Danielle%20and%20Stacie.pdf
  3. “Joining Forces on ICD-10-CM/PCS,” June 2013, http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050205.hcsp?dDocName=bok1_050205.
  4. “Medical practices need to include healthcare payers in the ICD-10 transition,” May 20, 2015, http://www.icd10watch.com/blog/medical-practices-need-include-healthcare-payers-icd-10-transition; “Three types of alignment for better payer-provider relations,” accessed Dec. 23, 2015, http://healthleadersmedia.com/content/HOM-233186/Three-types-of-alignment-for-better-payerprovider-relations.html
  5. “How regulations changed reimbursement in 2015, outlooks for 2016,” Dec. 22, 2015, http://www.healthcaredive.com/news/how-regulations-changed-reimbursement-in-2015-outlooks-for-2016/411213/

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