Large insurers worry what will become of the hard work and money expended on the conversion if some providers get their way
When Dan Rode, the vice president for policy at the American Health Information Management Association, heard that the Department of Health and Human Services was proposing a one-year delay on the conversion to ICD-10 diagnostic codes, he figured that the biggest health plans in the country had some rethinking to do about their in-house tech programs.
Rode says that WellPoint, UnitedHealthcare, and other companies were on schedule to hit the original deadline of Oct. 1, 2013, and needed to start preparing to conserve the ICD-10 translation work they had completed. But some of the smaller plans probably welcomed the delay. The new deadline is Oct. 1, 2014.
America’s Health Insurance Plans has already indicated that it’s not opposed to a temporary delay, but the industry lobbying group is also seeking concessions on some of the government’s demands under the Affordable Care Act, including the opportunity to continue to account for related technology costs outside the health plans’ medical loss ratio (MLR) cap for overhead. More on that later.
Long time coming
The main point is that few health insurers would want to wait indefinitely. ICD-10-CM, the International Statistical Classification of Diseases and Related Health Problems, 10th Revision Clinical Modification, is the U.S. version of the latest code set from the World Health Organization to categorize diseases. Payers, doctors, and the clearinghouses that often handle their bills have had decades to grow accustomed to the 13,000 diagnostic codes that make up ICD-9, the precise numerical language that describes a patient’s problem and dictates payments. They’ve also had more than 20 years to become familiar with the fact that ICD-10 standards were being rolled out in many countries around the world.
“The only alternative is ICD-10,” says Rode. “It’s been suggested that we wait for ICD-11, which internationally won’t be available until 2016.”
To adapt ICD-11 to the complex U.S. health care market, the effective date would have to slide back to 2020. That would disrupt the whole attempt to move to higher quality health care and a value-based payer system.
“Everyone believes that getting a more nuanced set of data is going to yield positive results,” says Dave Biel, a principal in Deloitte’s health care technology practice, who has been working with insurers on the transition. Richer analytics and data capability are at the core of the move to better outcomes.
Biel calls ICD-10 the “gold at the end of the rainbow. It’s just that the rainbow is a long one.”
Many doctors, some with influential lobbying groups in Washington, D.C., had a completely different reaction. Physicians in the American Medical Association, the Medical Group Management Association, and others have laid out detailed arguments why a one-year delay was just a good opportunity to head back to the drawing board. They made it clear that they wouldn’t mind an indefinite delay for implementation and, in fact, would like to see ICD-10 killed.
“I’m just back from our Florida chapter meeting, where I sat in on ICD-10 sessions,” says Robert Tennant, senior policy adviser at the MGMA. “The angst and the anger were palpable. Practices are concerned about cost. They’re just not seeing the value of moving to ICD-10. They also worry about the potential of claim payment disruption and whether there will be sufficient coding expertise in the practice, as there’s already a lack of ICD-9 coders.”
For many insurers that tried to comply with the original mandate, though, the delay will add a layer of administrative effort.
“For the ones which are ready,” Rode says, a one-year delay “means they essentially have two different adjudication systems in their organizations.” They have to maintain the ICD-10 product — an entire billing system built on 68,000 ICD-10 diagnostic codes — while using ICD-9 until the switchover is made.
“When the announcement went out, those with a mature program looked at the delay as something that could take the wind away, especially among the large payers and providers,” says Biel. “It can take months to get a program as large as this going. The concern was that there would be a massive halting sound.”
Now, he says, “most are a bit concerned about another year of cost, but many are happy to have an additional year to shore up different aspects of their program that weren’t so strong.”
For its part, America’s Health Insurance Plans didn’t object to the one-year delay, but it drew a line against anything more than that. Delaying ICD-10, adds AHIP, should trigger a review for other deadlines under the ACA.
“Where the problem comes in is in documentation,” Rode says. “If you have a more detailed coding system, you have to document better. You have to tell me whether it was the right arm or the left arm. You have to tell me the source of the problem. I’m not a coder, but there are lots of other areas that need to be in the records.”
Insurers already gained one key concession from the government when they won the right to count ICD-10 conversion costs for 2012 and 2013 as a quality improvement under the ACA, putting the expense in the care column and outside their cap on administrative costs under the MLR rule.
But many providers say the 68,000 codes in the U.S. edition of ICD-10 are an overwhelming bureaucratic blizzard that is hitting at the same time other tech mandates are descending on practices. The U.S. version of ICD-10 is styled for multiple payers, with a far more complex set of codes than doctors face in single-payer systems. (Germany, for example, uses about 13,300 codes; Canada about 17,000.) A two-year delay would provide breathing space in which to re-evaluate the cost of the conversion and figure out if ditching it altogether made more sense.
The MGMA and the AMA want the whole timetable scrapped, sending regulators and industry leaders back to the drawing board to figure out exactly what this will cost and how the expense will be borne.
“We don’t know what the impact is going to be — whether there’s any return on investment or how long it would take to achieve,” says Tennant. “There are a thousand questions that have to be answered, on payment and policies, problems with testing, issues that have to be resolved. We’re forcing providers to change all of their work flow, but we don’t know what each plan will require.”
He uses sinusitis as an example. There are six ICD-9 codes for the condition. One is for unspecified sinusitis, he says, which quite a few providers use routinely as there’s no payment differential between unspecified and specified. Under ICD-10, there are 14 codes to pick from, including unspecified. “Is a plan going to accept unspecified?” asks Tennant. “If that’s the case, and all providers do is submit unspecified, where’s the value to the plan that invested in the new system?
Faster payment of claims
Rode argues that ICD-10 is a plus for physicians. “If I don’t have information, I suspend your claim, send you an electronic message, or call you or send you a letter. Now you have to put the information together and get back to me.” With ICD-10 “it gets more specific. You can get good at it, get your claim paid faster.”
Done right, the technology handles the transaction without getting people directly involved to sort out a problem over a single bill. “As more information is collected, we’ll see what we’re seeing with CMS,” adds Rode. “Data will be gathered, and we’ll have a better way to determine what’s most cost-effective and the best quality.”
Paul Lendner ist ein praktizierender Experte im Bereich Gesundheit, Medizin und Fitness. Er schreibt bereits seit über 5 Jahren für das Managed Care Mag. Mit seinen Artikeln, die einen einzigartigen Expertenstatus nachweißen, liefert er unseren Lesern nicht nur Mehrwert, sondern auch Hilfestellung bei ihren Problemen.