HIMSS News
5010, ICD-10: Establishing Industry Glidepaths
By Phil Dodds
As we head toward the last few months until the 5010 deadline, let’s think about how similar industry requirements in the future could be structured to make their adoption more successful. Regulations that require software changes for thousands of interconnected healthcare entities should be structured to include firm, realistic “glidepath” stages. This will reduce confusion and simplify complexity caused by the interconnectedness of these systems.
“Glidepath” is a project management technique that ensures there will be time to detect and repair problems as the project comes to completion. Visualize an airplane landing down a long runway versus an abrupt landing on an aircraft carrier. Long runways allow for less expert pilots and less chance of large failures. There should be a way to ease into the new software without putting anyone at risk. Having no glidepath means each surprise and mistake becomes much more severe.
For simple projects, there may not be a glidepath considered in the plan, but the project is likely to succeed anyhow. However, whenever the consequences of failure are severe or when the project is complex and interconnected, then staging a glidepath is critical.
We find this scenario with both 5010 and ICD-10 at the extreme; yet, there is little true glidepath planned with 5010 and none with ICD-10.
The problem is not that we were not given enough time to succeed. The official lead times for 5010 and ICD-10 have been years. Organizations have had time to take this effort seriously and get their portions completed. However, there is potential problem coming for provider organizations that is out of their control.
The root of the problem is consequences for failure (snafus) and the incentives to be ready ahead of the deadlines do not converge. Focusing on insurance claims, there is no planned incentive or mandate for insurance payers to be ready ahead of the final deadline; yet, the consequences of any mistake fall to the provider organizations (with clearinghouses caught in between).
In 5010, an entire year was given for payers to test their systems, but there is nothing in the plan that prevents an insurance payer from beginning to accept 5010 claims near (or even after) the deadline. This will not leave much (or sometimes any) time for providers to have real claims pass through the payer’s adjudication system. If problems are found, providers will not be allowed to rely on 4010 style claims. Payers are likely to reject 4010 claims even if problems are discovered with their own system or with the provider’s claim submissions. Providers will be caught with no glidepath and may bear the financial brunt, even though they could not influence when the payer would be ready.
For ICD-10, the situation is even more extreme. The ICD-10 regulation will have broader and deeper impact than the 5010 regulation; yet, only a single day is scheduled for every healthcare related entity to come together at once. This is a crash landing scheduled right into the plan. When problems arise, every organization in the circuit will be affected, with providers at highest risk losing a large percent of revenue. The regulation is counting on all of this to work right the first time it is turned on, which should be a red flag warning to us.
The solution for regulations similar to 5010 and ICD-10 is to allow for a transition period for the provider organization after the insurance payer is live with its portion. This would mean giving provider organizations a time window (say, four months) from when a payer is live, before the payer would require ICD-10 diagnoses on claims. Providers would be allowed to send small targeted claim batches during the four month window in order to test the payer’s system and respond to the results. For 5010, this is exactly what is needed. For ICD-10, the story is more complicated, but the essential suggestion would be to establish more glidepath.
In future regulations, sensible accommodations for glidepath would allow for problems to be experienced and corrected before large numbers of claim rejections or denials put the provider organization at risk. This is one additional precaution that can be taken to reduce severe risk as thousands of organizations try to transition into these very important, but complex, regulations.
Phil Dodds has been designing practice management software for 16 years with gloStream, Sage, and Medical Manager.
