As I continue to listen to voices from across the industry as we move into the critical last 600 days before ICD-10 implementation, I am becoming concerned that our discussion is still stuck in silos (i.e. financial neutrality, a payer strategy and solutions, etc.).
Providers have an expectation that with improved clinical documentation to demonstrate complexity of care, they will see reimbursement trending toward more positive adjustments. The industry needs to convert the value proposition of each trading partner into a single metric that best will measure projected compliance and risk mitigation.
Yet how do we align the definition of ICD-10 readiness with that of compliance, across the industry? Unfortunately, we see minimal evidence of any meaningful collaborative strategy or planning to look beyond one’s own business and to take into consideration the challenges faced by the trading community at large.
One of the more common statements about the issue we hear all the time is “We are going to be ready (though readiness is still loosely defined), but I am not sure if the providers will be ready.” Likewise, providers also profess to be working diligently toward compliance, but they “don’t know if their application vendors will be ready.”
We only will achieve industry-wide compliance if we expand our respective internal visions to include a full trading partner strategy that must establish a definition of ICD-10 readiness. This strategy will be unique in that it will guide how the trading community makes decisions about mapping standards and payer clinical editing standards and criteria, which should be aligned with providers’ CDI improvement programs and the metrics commonly used to measure and evaluate ICD-10 compliance before testing can begin (or before the “switch is flipped.”)
Looking to other industries, for example life sciences and banking, for benchmarks can offer valuable lessons. Both of those industries once migrated from a predominately manual, paper-dependent supply chain to a fully electronic flow of information via a strategic approach, offering great examples of the prototypical trading community model and governance.
As other industries created trading partner community/e-supply chains, it became obvious that they only could be built once trust had been established across the community. To build trust, there needed to be mutual opportunity for all to voice a point of view in order to achieve consensus, establish standards and settle on a risk mitigation strategy.
In each of these cases, a critical step in building the trading community was identifying quality partners and vendors to participate in building the trading partner/e-supply chain. High-volume, high-cost partners were not automatically included in the respective trading communities, as membership was based on quality indicators and the ability to meet standards and/or business and technology requirements.
ICD -10 compliance will not be achieved in an organizational vacuum or in silos, meaning that now more than ever we need a conversation that builds trust among stakeholders. This will occur only if we listen to all the relevant voices and formalize a set of agreed-upon standards and metrics that will define how to measure industry-wide success of ICD-10 implementation – a process that must involve examining outcomes of end-to-end testing across all internal and external trading partners.
Internal business unit service level agreements may need to be reviewed and renegotiated based on the quality indicators of the various trading partners. External vendors and trading partners also may need to review their performance standards based on the ICD-10 testing metrics and standards established by the trading community.
The following outlines the value of forming a trading partner strategy:
- It will span geographic areas and business practices;
- It will normalize data; and
- It will set the stage for future relationships dependent on data to be managed.
Some of the decisions that need to be made in establishing testing standards and risk mitigation only can be achieved through dialogue and consensus. The following are important aspects to consider as a trading partner strategy is being planned:
- All trading partners, both internal and external, need to have a voice in the testing strategy and overall roadmap.
- Testing use case criteria should start keeping in mind the results the trading community wants to achieve.
- There must be consensus on the clinical profiles and/or episodes of care that will be tested across each organization and in the trading community at large.
- It is important to create a risk mitigation strategy in selecting the testing use cases.
- There should be a random event use case based on rare or complex multiple diagnoses and/or complicated patient trajectory processes. The trading community should include the complicated events in their testing strategy and roadmap.
The true potential in taking on this challenge can be seen in how it could help resolve ICD -10 code mapping issues between, for example, a software vendor that has built a code database in its application, a clearinghouse that has to align itself with the new business rules, a payer working to adjust its protocols and the physician documenting information in a medical record. Without trusted standards, the potential for an increased volume of pending or denied claims is a risk that demands a mitigation strategy. Exploring the possibility of working with the trading community at large in building a new ICD-10 testing strategy is imperative.
A key goal tied to ICD -10 implementation is to protect the consumer (patients, members, etc.) from complications presented by the new coding set. Establishing measurable metrics reflecting overall industry success will be key in managing the risk of change and the challenge of “keeping the lights on!” We only can get there by sharing goals, working together and building bridges of shared experiences. Health plans and some large integrated delivery network operators have been several early adopters and innovators, as they have analyzed projected ICD-10 impacts on their business models and achieved an understanding of most of the impacted business units. What’s more, they have created executable roadmaps to compliance. The late adopters will struggle to achieve compliance, and there is the potential that they will not meet critical deadlines for many reasons: financial, operational, or due to simple lack of understanding of impacts.
Our industry-wide success only can be achieved by trusting in a common goal and building bridges through trusted partner models.
About the Author
Ellen VanBuskirk, senior principal in business consulting for Infosys Public Services, is a healthcare consultant focused on compliance strategies with a mission to work across the Healthcare value stream to meet regulatory challenges. VanBuskirk has conducted business development efforts in support of healthcare compliance and reform, as well as ICD-10 transformation by both provider & payer organizations. With more than 20 years of success in leading business teams and identifying emerging opportunities and challenges in the healthcare industry, VanBuskirk brings deep expertise in health plan regulatory and compliance initiatives, including healthcare reform, ICD-10 transformation, meaningful use, HITECH and HIE.
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