Note to All Healthcare Organizations: “When You Come to a Fork in the Road, Take It!” | Sherpas in Blue Shirts

Posted On May 23, 2011

American baseball great Yogi Berra’s second claim to fame is for being one of the most quoted figures in the sports world. Best known for his deceptively simplistic observation, “It ain’t over till it’s over,” his philosophy is plainspoken, down-to-earth, and honest. Stay humble. Trust your instincts. Most importantly, act, as in another of his famous quotes, “When you come to a fork in the road, take it.”

U.S. healthcare organizations are right now at the proverbial fork in the road with healthcare reform and the implications it will have, whatever form it finally takes. The magnitude 9.5 issue they are currently facing is compliance with the 2011, 2012 and 2013 deadlines for reimbursement – ICD-9 to ICD-10, and HIPAA 4010 – 5010 transformation. Compliance will significantly impact the majority of administrative and financial functions in healthcare provider and payer organizations, including substantial analysis and changes to pricing rules, policies to manage adjustments to old claims, and eligibility rules definitions. Claims and payment calculations will be altered based on changes in the contract and adjust rules. Charges for an expanded set of codes will require adjustment. Rule sets for defining high-risk patients will be expanded. And this is just a small sampling of all the challenges healthcare organizations will need to address.

A client recently asked me, “But what if the healthcare reform legislation is overturned?” The reality is that this set of rules has been legislated separately, we are out of ICD-9 codes, and the system, whether within a reform bill or not, will go forward. The client then asked if deadline extensions will be granted as we have seen in past reimbursement coding efforts from Diagnosis Related Groups (DRGs) to Universal Claim Form compliance. Another reality is the price any organization would have to pay for non-compliance, and the revenue disruption that will result, is not worth gambling on extension grants.

Unable to delay the looming deadlines, compliance with such massive scope regulations is forcing healthcare organizations to plan for extensive and costly internal and external resources, and most of the large onshore and offshore healthcare service providers are clamoring and competing for these $100 million+, multiple year projects. And each one claims to have a solution and multi-faceted approach.

Another reality: I have been working with both onshore and offshore service providers regarding the ICD-9 to 10 and 4010 – 5010 transformation since 2008. Healthcare payer and provider organizations have been slow to define the real issues, and service providers have been slow to develop the solutions. There is an interesting mix of service offerings including compliance programs, impact analysis, testing, crosswalk, and remediation automation programs, and a number of service providers have one stand out piece of the puzzle. But not one has emerged with the complete package of services, and as a result, buyers must take great care when researching and deciding on external support. In fact, their fork in the road answer may well be a combination of very carefully selected tool sets and provider companies.

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