More than one in five of all  consumers who are covered under  individual health plans today are insured by companies that spend more than 30 percent of the premium dollar billed on administrative costs.  And, more than one in four are insured by health plans that spend between 25 and 30 percent of every premium dollar on administrative costs.

However on November 22, 2010 the Obama Administration’s regulation implementing  new standards for the “medical loss ratio” provision of the Affordable Care Act will make the insurance industry more transparent and is intended to enable consumers to purchase health insurance that provide more value for every dollar paid for premiums.

Estimates are  that up to 9 million Americans could be eligible for rebates starting in 2012 worth up to $1.4 billion.  The average amount that could be rebated per person could total $164.  MLR rules are in effect now in 2011 and payment of rebates is mandated to begin in 2012.

This creates a double bind for health plans who already must spend more of their IT and operations expenses on compliance with new health care standards including the EDI standard HIPAA 5010 and medical coding standard ICD-10.  If a plan is wasteful and does not provide good value, then the MLR rules will have a favorable effect fo that plan’s members.  On the other hand, ICD-10 is expected to be expensive and span over three years.  We believe that the MLR rules could challenge some health plans to squeeze in new expenses in an already tight fifteen percent of premium dollars received.   ICD10, HIPAA 5010, and other regulations continue to challenge the health care industry.  Meanwhile, health plans with Medicare Advantage contracts are also investing in quality improvements to access federal incentives under the 5-Star Rating system.    The 5-Star system is another method that the government is already mandating to improve the quality of care, provide incentives for high performance and penalties for poor performance.

We expect collisions in these various initiatives, which have overlapping impact and in some cases redundant mandates.

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Implementing ICD-10 is more than just IT. Medical management and the opportunity to improve case management and pre-authorizations, decrease appeals, allow pre-authorization policy to increase auto adjudication allows for more “one and done” and touch-less claims.

If you aren’t looking at medical policy management and its inter-twined relationship with ICD-10, then you are not by definition looking at revenue cycle management either.   Our firm has been working with clients on HIPAA 5010 and ICD-10 preparedness, and also behind the scenes we have spent quite a bit of time looking at medical concepts and their relationships to ICD-9 and how those change in ICD-10.  Our past work in SNOMED has helped.   Medical policies in XML, working in ways we cannot now conceive of will become common place in the future.

Systems implemented without looking at the way ICD-10 can help your company innovate will be leaving value on the table. ICD-10 implementations should be both about a view of the minimum to comply and the extra value that can be gained. He who implements ICD-10 without a thorough grasp of these issues is doomed to substandard results. Medical management under ICD-10 will require a new view of clinical data and an audit trail from ICD-9 to ICD-10. An ICD-10 assessment from a knowledgeable company can help show where opportunities are for your company.

We urge you to start the process now if you haven’t. It is more complex than you think.  We understand, if you are a payor membership has declined, budgets are tighter.  If you are a hospital or other type of provider, you most likely have been working on Meaningful Use and Electronic Health Records.  Getting started with a business roadmap and a relatively small investment in an ICD-10 Assessment with our firm can be a good way to start.  Contact us now at info@noworldborders.com to start the conversation.

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