Payers Take Forgiving Stance in Accepting ICD-10 Claims

How lenient are major health insurers willing to be when it comes to accepting providers’ ICD-10 claims? Humana and UnitedHealthcare are giving latitude in the specificity of the new codes, at least for now.

“We made the decision, as I think most payers did, that we’re not going to drive specificity into the early stages of the implementation because it was going to drive so much complexity and misunderstanding,” said Sidney Hebert, Humana’s vice president of provider network operations, on Monday at the Medical Group Management Association conference in Nashville.

Hebert made the comments during an ICD-10 town hall meeting at MGMA15 in which he laid out the initial approach of health insurers to reimburse for the new code set. “We’ve all pretty much adopted an implementation based on what I call ‘medical equivalence’ where everything we do in our systems is based on what is medically equivalent in the ICD-9 world and the ICD-10 world,” he argued. “The goal initially is not to drive specificity. It’s to drive accurate care.”

This leniency when it comes to specificity of codes may explain why both Humana and UnitedHealthcare are reporting that the ICD-10 transition is going well since the new code mandate went into effect on October 1, with very few claims being denied as reported by the two payers.

Ross Lippincott, vice president of provider regulatory programs at UnitedHealthcare, said that his company has taken the same approach to code specificity—or lack thereof. “Our goal was no new specificity out of the gate,” commented Lippincott. “We all need time to let the dust settle and get some experience with just making that neutral transition. And, then, looking for what value the industry can get from additional specificity later.”

The position of these payers appears to resemble recent policy announced by the Centers for Medicare and Medicaid Services that it will reimburse incorrectly-coded claims under the Part B physician fee schedule, provided that the incorrect code is from the appropriate ICD-10 code family. The one-year “accommodation” period was the result of an agreement between CMS and the American Medical Association. Likewise, Humana intends to maintain its policy of code non-specificity for about a year.

“Over time, as we learn more, you’ll see policy adjustments and coding alerts coming out of the payers saying ‘here’s what we’ve discovered, here’s how we’re going to measure it, here’s what we’re requiring around specificity,’” added Hebert. “But, I’d say we’re probably in pretty good shape for the next year.”

Lippincott indicated that UnitedHealthcare believes it will take “a good six months of time to really allow that transitional period to complete before we would feel that we have enough information experience with the codes to start to say what additional value we can derive from those codes.” He reassured providers that any changes to the health insurer’s policies would be communicated in advance so they can plan accordingly.

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Photo courtesy of: Medical Coding News

Originally Published On: www.healthdatamanagement.com