Becker's ASC Review

48 Coding & Billing Blue Cross Parent Posts $281.9M Loss in First Year of PPACA Exchanges By Ayla Ellison T he largest nonprofit health insurer in the country, Chi- cago-based Health Care Service Corp., which is the Blue Cross & Blue Shield insurer for Illinois, Montana, New Mexico, Oklahoma and Texas, reported a $281.9 million loss in 2014, compared with a $684.3 million surplus the year prior, ac- cording to a Crain's Chicago Business report. Last year was the first year Americans could purchase health insur- ance through the public exchanges, causing the number of medical claims to rise significantly, which affected HCSC's finances, according to the report. For instance, the health insurer, which had nearly 2 mil- lion members as of March 31, saw its prescription drug costs soar 43 percent last year. Although the health insurer posted a loss for the year, its revenue in- creased 22 percent in 2014, according to the report. HCSC expects to have a more positive financial picture in years to come. "Over time, as we have more experience on the exchanges, and that market stabilizes, we expect to see lower expenses and results that will maintain our financial strength while continuing to provide our members with cost-effective products, services and peace of mind," an HCSC spokesperson said in a statement released to Crain's. n ASCs face a number of risks while transitioning to ICD-10, but preparation and smart investments can mitigate most of the potential pitfalls. While the implementation deadline is fast approaching, it's not too late to start plan- ning. The following is a step-by-step breakdown of how ICD-10 will affect each aspect of a facility's revenue cycle process and what decision makers can do today to avoid an expensive slowdown come Oct. 1: Information technology Software and other IT tools provide the foundation for properly managing a facility's revenue cycle process. But as the old saying goes: garbage in, garbage out. That is, if IT systems are not up-to-date and tested well before Oct. 1, productivity and cash flow could suffer as a result. In many cases, script updates, workarounds and other simple fixes can elimi- nate several of the issues involved with the transition. Small facilities, too, may not have a large enough dedicated IT staff internally to handle all of the upgrades, so outside resources might need to be secured. Pre-surgery Prior to the procedure, business office staff must incorporate codes into pre- authorization, scheduling and other requisite steps to prevent reimburse- ment issues on the back end. ICD-10 implementation will have an effect on this process. Staff should understand how ICD-10 coding changes interact with individual insurance policies, including any role they may play in au- thorization and medical necessity. Forms also may need to be updated and outside sources contacted to make sure the most current requirements are being met. Physicians Continuing physician education is a critical component to any success- ful ICD-10 implementation effort. Medical staff must be cognizant that coding will be much more specific, which will require far more extensive documentation than was necessary in the past. In addition to documen- tation, AHIMA recommends that physicians understand how the ICD-10 transition will affect electronic health records and superbills within their practices. EHR systems are updating their software to include prompts that ask the physicians more detailed questions when they're entering patient information through the interface. Software providers, too, are offering ICD-10 training sessions for physicians, which can preempt implementa- tion issues after Oct. 1. Coding For many professional coders, ICD-9 has been the prevailing system for their entire careers. They've memorized common — and frequently not-so- common — diagnosis codes through their many years of practice. After Oct. 1, those days will be over. With 50,000 additional codes to sift through, the coding department will be the epicenter of the post-ICD-10 slowdown. Still, there are a variety of resources available to lessen the blow on Oct. 1, includ- ing online courses, boot camps, conferences and other continuing education opportunities. Unspecified ICD-10 codes may prove to be a particularly thorny issue for coders during implementation. Currently, unspecified ICD-9 codes are wide- ly accepted. That could change, however, as many carriers are expected to adjust their policies after Oct. 1. Claims and charge posting ICD-10-related inefficiencies also will take a toll in the claims and charge posting step of the revenue cycle process. And for good reason: ICD-9 codes are between three and five digits, while ICD-10 codes are between three and seven digits. In some situations, that's an instantaneous 40 per- cent increase in keystroke volume overnight, which may contribute to hours of additional labor, considering some facilities process thousands of charges per day. Facilities should inventory their payers to determine when they are ac- cepting the new codes. While all HIPAA-compliant ASCs must use ICD- 10 after Oct. 1, some workers' compensation cases may fall under the old system for an indeterminate length of time. It's also important for ASCs to initiate contact with their clearinghouses as early as possible, so that their specific processes are understood and any new processes are tested and implemented by Oct. 1. Accounts receivable A/R managers are expected to shoulder the brunt of external ICD-10-related challenges after Oct. 1, as they'll facilitate frontline communication with pay- ers and the claims department to refine processes and head off future road- blocks. Unfortunately, A/R teams also will face many unknowns heading into the deadline, as they can only predict potential payer denials and other nuances of the switchover. Unspecific codes are expected to play a lead role in this confusion. While the U.S. Centers for Medicare and Medic- aid Services has indicated that unspecified codes will still be accepted in many cases, it's too early to say definitively how all private payers will address them. A well-designed ICD-10 implementation plan that includes contingen- cies, defined responsibilities and the allocation of appropriate resources can mitigate most post-Oct. 1 challenges. With so much at stake before, during and after implementation, delays must be avoided at all costs. And keep in mind: The World Health Organization is already develop- ing ICD-11. n

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