ICD-10 – People, Process & Technology

 

The significant increase in code classifications will affect how departments function within themselves, with each other and with outside organizations. As payers take the time to become educated about ICD-10 and 5010, it becomes clear that the impacts are not contained within one area of the business, such as claims.

In fact, there are broad reaching, unavoidable requirements that will impact how payers operate moving forward.  A workflow analysis to identify potential gaps in process, and redesign of workflows and product configurations to accommodate those changes is critical to preparing for ICD-10 implementation and transaction and code transitions and configurations that result in claims being denied or billed under both coding systems.  Consider the effects that ICD-10 will have on Explanation of Benefits (EOB) statements.

This seemingly simple piece of the puzzle has far-reaching impacts across people, process and technology. The provider will need to give the proper codes. The payer will need to accept those codes to determine payment and issue an EOB. Members need to receive communications that educate them about new information appearing on their EOBs. And customer service representatives need training and preparation to intelligently answer members.  Many organizations skip this analysis stage and go right to implementation. Spend time to assess the impact of the codes

Disconnected process can lead to missed requirements, workflows that don’t work and missed deadlines

With a strong understanding of the people and process changes needed to support ICD-10, payers can next evaluate the technical impact of the change and determine the best way to meet those changes. As we and our clients are learning, changes in technology required by ICD-10 and 5010 compliance will affect all core areas of payer operations, including patient care, pharmacy, provider systems and reporting.

For more information on ICD-10 Assesments & Consulting, visit www.noworldborders.com/icd-10.html

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Michael F. Arrigo

Michael is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. His vision for the firm is to continue acquisition of skills and technology that support the intersection of clinical data and administrative health data where the eligibility for medically necessary care is determined. He leads a team that provides litigation consulting as well as advisory regarding medical coding, medical billing, medical bill review and HIPAA Privacy and Security best practices for healthcare clients, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, physician compensation, Insurance bad faith, payor-provider disputes, ERISA plan-third-party administrator disputes, third-party liability, and the Medicare Secondary Payer Act (MSPA) MMSEA Section 111 reporting. He uses these skills in disputes regarding the valuation of pharmaceuticals and drug costs and in the review and audit of pain management and opioid prescribers under state Standards and the Controlled Substances Act. He consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises ERISA self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been interviewed quoted in the Wall Street Journal, New York Times, and National Public Radio, Fortune, KNX 1070 Radio, Kaiser Health News, NBC Television News, The Capitol Forum and other media outlets. See https://www.noworldborders.com/news/ and https://www.noworldborders.com/clients/ for more about the company.