Providers can make all the right moves when it comes to preparing for ICD-10. But unless payers are ready to accept the new code set, next fall’s transition could be a bumpy one.

That’s why it’s important for physicians to complete their system readiness and begin testing ICD-10 submissions with payers as soon as possible. End-to-end testing simulates real-world claims submission to determine if payers can accurately recognize, adjudicate and pay an ICD-10-coded claim. 

“The good news is that most of the major payers should be ready for end-to-end testing early in 2015,” said Susan Moore, senior manager, web2pro Business Performance Services, and co-chair of web2pro BPS ICD-10 Program for Readiness. “The bad news is that there are a lot of small- to medium-sized insurance companies that may struggle to provide a robust testing environment through the first half of the year.”

Simulated Testing

Uncertainty surrounding payer readiness reflects the enormous task insurers face as they prepare for the October 1 conversion. Among other duties, each company must evaluate tens of thousands of automated rules used to identify and process claims and then translate those rules from ICD-9 to the more robust ICD-10 nomenclature.

To make sure these conversions work, it is essential to replicate the full claims submission and payment cycle via end-to-end, or `round-trip,’ testing, Moore said. Merely receiving payer confirmation that an ICD-10 claim was received and recognized is not enough, she added. Instead, the insurer has to demonstrate their ability to appropriately identify and adjudicate an ICD-10 claim, then return their response to the provider via an electronic remittance advice, or ERA, once the process is complete.  

“If the payer does not push the claim through their adjudication process, there is no way to know whether it will be denied or paid when ICD-10 is implemented in the production environment,” Moore said. 

While the vast majority of electronic claims travel to a clearinghouse before being sent to an insurer, the clearinghouse is simply a conduit and does not evaluate claims for coding compliance, Moore said. The clearinghouse can and should communicate with payers about ICD-10 testing, she added. But it is the provider’s responsibility to determine if, how and when commercial payers will offer end-to-end testing.

The Centers for Medicare & Medicaid Services (CMS) plans three end-to-end testing events in 2015. The agency will use representative claim samples solicited from clearinghouses. Providers that do not use a clearinghouse but submit directly to CMS must register to be considered for the testing, which will be held during the weeks of January 26-30, March 2-6 and June 1-5.

A Pro-Active Approach

Moore said a physician group’s first step in preparing for simulated submissions to both CMS and commercial carriers is to communicate with technology or billing vendors and determine when front-end platforms will be ready to accommodate ICD-10 codes. Once those dates are established -- and assuming the group’s documentation and coding can support ICD-10 test claims -- practice managers should reach out to payers to determine testing plans.

Key questions for carriers include:

  • When are you going to start testing?
  • Will the testing be true end-to-end?
  • How will the process be conducted?
  • Do providers need to register to participate and/or schedule a specific testing date?

Practices should also monitor payer websites for information about planned testing dates or events, and communicate with clearinghouses to find out what they may have heard from specific payers.

Although groups should reach out to all of their payers, Moore said, the initial focus should be directed toward insurers that compose the greatest proportion of reimbursement dollars. If a practice is told that the payer isn’t ready to test, or if no test dates are forthcoming, the group should continue to check back until they get answers. This will be particularly important with smaller insurers, who may be behind schedule in their preparations and thus will have little time to announce testing plans.

After October

The CMS ICD-10 compliance deadline of October 1 looms large for most organizations. But some commercial carriers may plan to activate the new code set before or after that date. It is therefore important to ask about each insurer’s go-live date when communicating about testing.

Finally, practice managers should be planning the steps they’ll need to take after October 1. Moore said it will be critical to track denials on a daily basis for a number of weeks after ICD-10 claims submission begins. This will help practices determine whether an inordinate number of claims are being rejected and, if so, whether the problem is on the payer or provider side.  

Groups should also carefully track payments after the ICD-10 activation to confirm that payers are reimbursing at appropriate levels on all claims.

“Medical practices need to stay engaged and pro-active throughout each step of this process,” Moore said. “The stakes are too high financially to do otherwise. Groups that assume there will be another implementation delay, or that believe all pieces of this puzzle will fit together perfectly on October 1, can expect cash shortfalls and significant recovery efforts.”


About the author

web2pro Business Performance Services offers services and consulting to help hospitals, health systems, and physician practices improve business performance, boost margins and transition successfully to value-based care.