Will Payers follow CMS's "Advance Payment" Policy with ICD-10 Claims?
CMS's ICD-10 FAQs addressed accessing advance payments by stating the following: "When the Part B Medicare Contractors are unable to process claims within established time limits because of administrative problems, such as contractor system malfunction or implementation problems, an advance payment may be available. An advance payment is a conditional partial payment, which requires repayment, and may be issued when the conditions described in CMS regulations at 42 CFR Section 421.214." One of the conditions listed is, "the carrier is unable to process the claim timely."
Some providers have assumed that payers will follow CMS's lead on this issue and as a result feel there is no need to worry about delayed payments during ICD-10 transition. Unfortunately, it does not appear that payers have in place an "advance payment" option. For example, Aetna stated, "While Medicare may be making advanced payments available if Part B Medicare contractors aren't able to process claims within established time limits due to administrative issues, we don't plan on taking such action. Based on results from our extensive provider testing, we're confident that this won't be necessary."
With this information in mind, we encourage you to contact payers directly and inquire about their "back up plan" should their systems fail to process ICD-10 claims correctly. In the meantime, as suggested by ACA's ICD-10 Implementation Checklist, you may want to access reserved funds in preparation of the "go live" date.
Is Your Clinic Signed Up?
The article ICD10 Likely to Bring Payment Challenges states, "Call it payment policies, coverage determinations or reimbursement guidelines, third-party payers create custom, proprietary algorithms to govern the claims adjudication process. The protocols incorporate many factors - place of service, national provider identifier (NPI) and so forth - but the decision to pay - or pre-authorize to perform - often hinges on the diagnosis code."
Being familiar with each payer's clinical reimbursement guidelines or coverage determinations is of utmost importance. The attitude "we always got paid for that in the past" or "I have been billing this way for twenty years" will only lead to lost revenue and unnecessary write-offs. Take time to find your topmost payers' reimbursement policies for each and every procedure code rendered in your practice. Know for certain that your treatment plan, documentation and diagnoses meet the necessary payer requirements. It may help to create a folder and bookmark the online payer policies in your web browser or print this information and keep it in a binder for easy access.
You will want to check back often as policy updates including use of modifiers are updated quarterly by most payers. Be sure that your ICD-10 project manager has access to the online portals for your top ten payers in order to receive the most current information regarding ICD-10 claims submission. A great resource for recent updates can be found in each issue of ICD-10 Matters under the subheading, "Payer News."
Where is Your Clinic on the Implementation Timeline?
ACA has fielded numerous calls within in the past few weeks with regards to ICD-10. Although the majority of providers we spoke with are in the final stages of implementation, sadly some have not started. As a result we have received requests for a list of codes or a list of what steps they should take. Unfortunately, there is not a "quick start" method toward implementation of ICD-10. If you find your clinic in an unprepared state, ACA suggests that your clinic take the following steps immediately:
- Download ACA's ICD-10 Toolkit (can be purchased HERE)
Purchase ChiroCode's ICD-10 Manual - Transitioning and coding without a manual is simply not feasible.
Access ACA's ICD-10 Coding for the Chiropractic Clinic webinar; a member discount available HERE. This four hour comprehensive coding course with companion workbook will assist you in learning the steps needed for coding with ICD-10. The ChiroCode manual or other ICD-10 Code book is required.
Review or print the following free resources available on ACA's ICD-10 webpage:
- Click on the Implementation Checklist link and find your place on the Implementation Timeline.
- Complete an ICD-9 Assessment of your clinic and create a list of ICD-9 codes most often used in your clinic (worksheets available in the Toolkit). Convert those codes using the Mapping Tool (link available on the Tools tab in the Toolkit; directions can be found HERE).
- Print the Vendor Worksheet (available in the Toolkit) and contact your vendors such as your billing software and clearinghouse to be sure they are ready for ICD-10. Make any needed changes in your software, electronic record templates, and billing procedures.