ICD-10 Health Plan Office Changes

There’s more to ICD-10 than just learning a new code set and upgrading your software. The transition will affect every health plan department. Move your mouse over the icons below to see how ICD-10 is going to change the way you do business.

Sales and Marketing

  • Sales and Marketing will have to determine where there are diagnosis and procedure code dependencies and communicate with customers prior to implementation.
  • Decisions on potential benefit and rate changes will need to be discussed prior to implementation.

Actuarial and Underwriting

  • Greater levels of specificity in ICD-10 coding will affect criteria for underwriting and statistical reporting.
  • Completion of the high-level impact assessment and business case will assist the actuarial and underwriting area in preparing for the impact and remediation that is required for ICD-10 implementation.

Fraud and Abuse/Special Investigations

  • Software programs that are used as a means of fraud detection will need to be modified.
  • Fraud and internal audit departments should be prepared for changes to format, and type of information that may be requested.

Customer Service

  • Increase phone calls and inquiries from both members and providers will require additional overtime and training during transition.
  • Increased denials and reprocessing might cause disruption during transition period

Government Programs
(FEP/Medicaid/Medicare/Compliance)

  • Government agencies that administer these programs will need assurance from health plans that they're compliant with ICD-10-CM/PCS implementation
  • Claims payment accuracy and continued data reporting are of extreme opera­tional importance so all systems and processes will need to be evaluated.

IT/Enterprise Data Warehouse (EDW)

  • Each system, application, interface, program, extract, algorithm, and report must be evaluated to determine diagnosis and procedure code dependencies.
  • Robust testing is a must.

Claims

  • ICD-10 will change how claims are processed and will require testing prior to implementation.
  • Claims analysts will require education on new codes, possible overtime during transition to ICD-10.

Provider Relations

  • Provider Relations will need to work more closely with  physician office pre- and post-implementation  to ensure smooth transition to icd10
  • Provider representatives will need education on ICD-10

Policies (Medical/Reimbursement/Other)

  • Each and every medical policy will need to be reviewed and updated for the new ICD-10 code sets and nomenclature.
  • One major area of concern within the clinical realm is the area responsible for care/case manage­ment and utilization review.

AAPC has nationally renowned ICD-10 experts who have been hard at work for years developing training and resources to guide your business through the transition.  Whether you’re large or small, we have solutions that will fit your needs.