HLM: Where are these losses coming from?
Assistant Professor in Biomedical and Health Information Sciences at UIC
Boyd: We have three categories: An incorrect mapping, which is flat out wrong, too specific, where you get a whole lot more information, and too general. If you have more detail you can detect fraud. If it is too specific and a patient gets reassigned multiple codes by different clinicians on the oncology side, that could be picked up as fraud by the insurance companies.
You have more specificity, but there is disagreement about that and you get flagged as fraud. The goal is to be revenue neutral from the insurance companies, but with the increased specificity there are other concerns.
This 2.9% (reimbursements) and 5.3% (billing charges) are what you really have to be careful about. This information loss is critical because as a clinician you put down what is medically necessary or correct. But if it is an incorrect mapping and the insurance company maps it incorrectly to 10 and their algorithm to approve what gets reimbursed [may not get you] paid.
HLM: If you are identifying these issues with oncology, which you say is a relatively simple code set, what does this say about potential problems on Oct. 1 with more complex subspecialties?
Boyd: I'm not comfortable making predictions. Right now, appropriately, most of the training for physicians and coders is 'What are the 10 codes I need to memorize?' So, when you're looking at transitioning to ICD-10 the first thing you do is train everyone for the new codes. The first pass of training, just so you can collect money, is training on what the new codes are and what the new interface is.
What we are talking about in this translation tool and this new paper is that second analysis of these reports that the hospital or the outpatient clinic runs. Right now we are just trying to get through Door No. 1 before we get through Door No. 2. When you begin that second step we're saying here are some problems.