Stay on top of your ICD-10 training, as denials from private payers will likely increase well before next October.
Elizabeth Woodcock, president of Woodcock and Associates, an Atlanta-based physician practice consulting firm, described ICD-10 as 2015's versions of Y2K: far less drama than many of us expected.
The fact that we haven't seen a flood of denials is due primarily to CMS observing a 12-month grace period-not refusing claims for lack of specificity during this period-and private payers following suit. Private payers are, for the most part, paying any claims that make sense. Woodcock warns, however, that this might not be the time to breathe a sigh of relief.
It is in the payers' interest to be flexible with claims at this point.
"Payers would have been out of their minds to bring the hatchet down post ICD-10" Woodcock said. "Physicians would have balked, and even Congress was on keen alert to make sure implementation went smoothly." Paying claims without too much attention to detail was a win for everyone. But don't expect this to last much longer.
Woodcock is already hearing from practices starting to see a smattering of denials. For example, denials for preauthorization requests (particularly on imaging), a payer parking claims in "medical review," and one that denied services because the diagnosis didn’t support the need for the procedure. Right now this seems to only occur occasionally. But it is wise to expect denials from private payers to gradually increase throughout 2016-long before CMS's 12-month grace period is over.
"This shouldn't come as a surprise," said Woodcock. "2016 will bring challenges related to ICD-10. It's inevitable."
Stay on top of your ICD-10 game, and you should be fine.
"Lean on all of the training and education you've invested in leading up to October 1, 2015. Code correctly; be sure that your staff know what, when, and how to get your services authorized, and stay on top of denials," Woodcock said.
It’s the same thing you've been hearing for a long time now. And that won't change next year.
Mohammad Rafieetary, OD, FAAO
I agree with the points made here, but it is shameful that healthcare providers have to deal with this constant state of games played, the fear of unknown, and changes in the rules of the game.
Thomas A Marsland, MD
Orange Park, Florida
We do not seem to be experiencing a significant increase in claim denials so far, but I believe in the motto of the Coast Guard as it pays to be "ever vigilant."