The Federal Register outlines the following pros from comments received on the adoption of X12 Version 5010 for HIPAA Transactions: 1) reduction in analysis time and minimization of companion guides; 2) improved efficiency through improved eligibility responses and better search options, reducing phone calls to providers and health plans; 3) improved electronic posting, automation of data entry of reimbursement information; 4) reduction in appeals and cost of sending and processing paper remittance advices; 5) improved clinical data and reporting of diagnosis and procedure codes with the implementation of ICD-10-CM and ICD-10-PCS; and 6) better understanding of clinical data and better monitoring of mortality rates, treatments, lengths of stay, and clinical reasons for seeking health care.[1]
Since the release of these statements in 2009, health plans across the nation have made, or have almost made the transition from 4010 to 5010 and are preparing to meet the ICD-10 mandate date of October, 2013. The industry seems to be pretty excited about all the new information that these changes are going to generate. However, are we appropriately prepared to generate, store, and analyze this information for improvements in our nation’s healthcare system?
It seems there is already a ton of information ready to be generated at our hospitals and health plans, but the appropriate tools are not in place to properly generate and present this information for influential decision making. If we are unable to fully understand the information being processed in our healthcare system today, it may be more difficult than we realize to understand new information and identify how the new mandates have helped us better understand healthcare spending and usage.
For example, health plans process authorizations and claims everyday but do they know what percentage of authorizations turn into paid claims? Or denied claims? Today, there are health plans that are unable to distinguish between approval or denial of an authorization or claim and of individual diagnosis and procedure codes included in it. More specifically, when a Medical Director is requested to review a claim or an authorization, he or she can approve some procedure codes and deny others. So if two codes are approved and two codes are denied, the reporting system will display that only one decision was made because only one form or review was completed. However, that is not the case. The Medical Director actually made four individual decisions. This hides the actual information from leadership, like which codes are being repeatedly approved or denied and why?
With the new ICD-10 codes that are much more specific than the existing ICD-9 codes, being able to better understand clinical data will require the implementation of adequate clinical reporting systems as well. Understanding why authorizations for certain codes were requested and then approved or denied may be more difficult than anticipated. The desire and hope to generate the necessary information does not mean that we are actually ready to generate it. The healthcare industry must invest in robust business intelligence tools to generate actual business intelligence that goes beyond basic metrics. Otherwise, we may be setting ourselves to fall into the same trap we are in today: too much data and not enough information.
[1] Health Insurance Reform: Modifications to the Health Insurance Portability and Accountability Act (HIPAA) Electronic Transaction Standards. Department of Health and Human Services. Federal Register, Vol. 74, No. 11, Friday, January 16, 2009, Rules and Regulations.
