ICD-10 causing "shock, awe, fear'

The healthcare industry is in a “state of shock and awe and fear” over ICD-10, said Annie Boynton, director of provider regulatory compliance (ICD-10) communication, adoption and training for UnitedHealth Group, speaking at the Massachusetts Health Data Consortium’s Dec. 13 program on the topic.

ICD-10 will cost a total of $1.1 billion and represents the single largest regulatory initiative UnitedHealth has seen in its history, Boynton said. It is 6.5 times larger than every other project combined in the next two years for the health plan which covers 70 million lives. “We have 600 FTEs devoted to this, 700 business applications are directly affected and we have 700,000 physician partners.”

Boynton’s biggest fear, she said, something that could cause “apocalyptic-type scenarios,” is a soft launch of ICD-10. A period in which both ICD-9 and ICD-10 are used and accepted would cause “mass hysteria.”

At this point, providers still don’t know how to code, Boynton said. Problems such as distinguishing between the letter “o” and the number zero and “1” and “I” result in incorrect and partial coding.

Meanwhile, testing poses numerous challenges. All stakeholders require testing data that can be used to test adequately and need to agree on when to test and exactly what to test. Just the creation of test data raises privacy concerns. “It’s all adding to a snowball effect,” said Boynton.

Providers need to know what questions to ask their vendors. “Go beyond ‘will you be ready on Oct. 1, 2014?’ With implementation of 5010, we saw providers turn testing over to vendors and took their word for it that they were ready. That absolutely cannot happen with ICD-10.” Each claim has to link to a plan. “You can’t just send a code through--the code has to trigger the appropriate next step.” That means it’s not likely that existing patient data can be used for testing.

Speaking of testing, Boynton said she is concerned about the possibility “that we have to train people who have never done testing. That’s a whole new constraint.”

UnitedHealth plans to select its largest providers by volume for testing as well as facilities ready to test when the payer is. External “end-to-end” testing may not be feasible, cost effective or available to many payers, providers, vendors and claim intermediaries, Boynton said. For example, UnitedHealth is too simply too large of an organization to make end-to-end testing work.

That testing requires a multi-dimensional approach, Boynton said, including:

  • Validation of clinical coding accuracy;
  • DRG comparison and revenue shift analysis;
  • Trading partner, EDI transaction tests;
  • Selected test claim processing; and
  • End-to-end claim process flow.

“I’m very concerned this may not be enough,” said Boynton.

Tufts Health Plan also is diligently preparing for the change. ICD-10 requires “thorough preparation to get the result we hope for,” said Patrice DeVoe, vice president of operations. Tufts started planning early for the ICD-10 transition, and focused on understanding the business impact of ICD-10 through requirements sessions while remediating the technology, she said.

The payer has learned that the transition will impact 80 percent of its business departments. Understanding the highest areas of business impact helped Tufts Health Plan prioritize the work, DeVoe said.

“Testing is the big monster when it comes to ICD-10,” she said. She advised her audience to “make sure it’s comprehensive and included in all phases. Focus on those areas that touch patients with internal and external entities." The health plan is taking a risk-based testing approach. Significant and comprehensive business testing efforts are required due to the scope of ICD-10, plus it demonstrates the impact of financial and operational outcomes, while continuing to validate system reliability with more production-like data permutations.

DeVoe listed the following objectives for external testing:

  • Establish enterprise-wide vendor governance and manage external testing partners throughout the ICD-10 program;
  • Coordinate with external partners to determine ICD-10 remediation requirements and testing plans;
  • Execute external party testing based on predefined plans; and
  • Develop a mitigation plan for external partners that are ‘at risk’ to Tufts Health Plan’s ICD-10 implementation plan.

Prior to its go-live, Tufts Health Plan will:

  • Assess ICD-10 impact to its contracts and payments;
  • Model the updated groupers and contract terms;
  • Start early reach out and communications with providers; and
  • Publish medical, payment and other associated policies in advance of the compliance date.

That early communication with providers is vital, she said, because after deployment, "it's too late to identify significant issues and fix them." After deployment, DeVoe said it will be important to monitor key performance indicators. "It's critical to keep an eye on those early on to make sure we can stabilize any issues as soon as possible."