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ICD-10 losers will end up being healthcare providers, panel says

Hospitals have the most to lose when it comes time for payer-provider contract negotiations, experts said.

Susan Morse, Senior Editor

Healthcare experts discuss ICD-10 at the Revenue Cycle Solutions Summit.Healthcare experts discuss ICD-10 at the Revenue Cycle Solutions Summit.

Two months after implementing ICD-10, revenue cycle experts say their world didn't collapse but not enough time has elapsed to declare the smooth rollout a victory. In fact, most expect to see some losers emerge.

"The bottom line is the people most at risk for losing are providers," said Joe Nichols, principal of Health Care Consulting. "Payers are like Realtors, they still get their commission."

Mike Simms, vice president of Revenue Cycle for Cone Health, also said hospitals have the most to lose, and said this would be an eventuality when it comes time for payer-provider contract negotiations.

[Also: Healthcare providers wait for rude-awakening after ICD-10]

"Hospitals are going to see decreases from the managed care players," Simms said.

Simms and Nichols shared their thoughts during an ICD-10 roundtable discussion on Monday at the Revenue Cycle Solutions Summit in Atlanta.

Price changes are a real worry for providers, as the specificity in the data provided by the new code set could lead insurers to lower the prices its pays based on the severity of the diagnosis code. The earlier ICD-9 code set had about 16,000 codes, but the new ICD-10 vocabulary features an estimated 70,000.

Stanley Nachimson, president of Nachimson Advisors, joked that some providers thought ICD-10 was a conspiracy of the health plans to cut payments to providers.

But, so far, hospitals are being paid about the same and are not seeing a reduction in payment amounts, he said.

[Also: With ICD-10 rollout past, healthcare providers brace for quality coding deadline]

Nachimson said he was surprised by the cooperation between health plans and providers during the transition leading up to the October 1 switch to ICD-10. There were some payers, such as Humana, which led the way, he said.

Diane Story, director of revenue cycle improvement for Roper Saint Francis Healthcare, said she expects ICD-10 will turn out to be revenue neutral in the long run, but "certain service lines will be losers," she said.

As for the winners, those who mine the data for information on population health now have an entirely new flow of highly specific data to analyze to find important trends, panel members said. The onus will be on providers to decide how to take advantage of that glut of data.

"I hope the big winners are the patients," Nichols said. "If we have better data we can truly improve the cost effectiveness of data. The folks that have the most control over the data, the most accurate data, will win."

In ICD-10, problems with data might not have anything to do with technology, and instead trace back to the physicians and coders who decide how to code claims, Nichols, a former physician, said. His own data shows that in 54 percent of all professional claims, the primary code was unspecified, he said.

As an example, Nichols said you should consider a patient admitted with a ruptured abdominal aortic aneurysm who was rushed into the operating room for repair. The patient had findings consistent with shock and severe hemorrhage, he said.

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In documentation, how and where the hypovolemic shock is listed can make the difference in thousands of dollars in reimbursement, he said.

Also, the practice of copying and pasting from the medical record cannot be done, as clone documentation does not meet medical necessity requirements for the coverage of services and therefore, will be denied.

There's a gap in trying to map the old ICD-9 codes to ICD-10 codes as well, Nichols said.

But while doomsday scenarios haven't played out when it comes to ICD-10, the panel did acknowledge a 40 percent drop in coder productivity.

Twitter: @SusanJMorse

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