The migration from the ICD-9 to ICD-10 code sets is one of the most extensive and risky conversion projects Healthcare Insurers will face. Conversion will impact organizational structure, business processes, healthcare policies and IT systems. The scope of this change presents significant risks to Insurers seeking to achieve financial and benefit neutrality to avoid undermining provider relationships.
The organizational transformation for “operationalizing” neutrality will require a 3 step approach:
- Data Impact Assessment: Insurers must assess which ICD-9 codes will have the greatest volatility within a forward and backward crosswalk clinical equivalency map. The primary criteria for assessing code data impact will include frequency of code use and cost of associated benefits.
- Systems Remediation: Insurers must determine all business processes and applications impacted by ICD-10. Applications that capture, store, send, receive, or edit diagnosis or procedure codes must be modified. Fields must support alphanumeric characters and expanded to support an extra digit. The new specificity of IDC-10 codes will impact corresponding application logic, business rules, system interfaces and data reporting.
- Operational Change:
- Case management, disease management, and utilization management must change to accommodate clinical management dependency upon code specific business processes.
- Medical policy management must have governance and audit-ability to ensure clinical mapping defensibility
- Claims processing will require more resources to validate, adjudicate and reimburse claims.
- Actuarial will require capability for cost projections based upon both ICD-9 and ICD-10 historical data.
- Provider networking and re-contracting will require changes to fee schedules and reimbursements based upon analytics to verify revenue neutrality
Because providers will have different timeframes for when they begin submitting ICD-10 codes, Insurers will need to be able to process both ICD-9 and ICD-10 codes. Insurers will require scalable, high performance healthcare data transformation. Using a medical ontology-based approach, Insurers will need comprehensive testing and automated comparison of ICD-10 results versus expected outcomes.
Analytics that use ICD procedure and/or diagnosis codes will change dramatically under ICD-10. The challenge will be in determining how best to take advantage of the greater specificity of condition, diagnosis and treatment data that will be available after healthcare organizations migrate to the ICD-10 code set. Business intelligence solutions will need to support ICD-9 and ICD-10 codes simultaneously during the transition. Reporting, efficiency and population risk models or other aggregation schemes must be fully remediated to support native ICD-10 as well as native ICD-9 codes. Architectural solutions must support technical platform compatibility and ease of integration in existing models.