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Three keys to successful RCM in 2014: ICD-10, new payment models, HIEs will all impact revenue cycle.

There is an ancient curse often attributed to the Chinese which says, "May you live in interesting times." Looking back on 2013 and ahead to next year, I think many revenue cycle professionals might feel like they are on the wrong end of this curse, with so much change this year and so much more to come. Looking back, provider organizations have made significant investments and advances to improve billing and reimbursement, but there are sure to be many "interesting times" ahead in the New Year. Here are three big ideas from 2013 to keep on your radar.

Preparation for ICD-10

With the ICD-10 deadline approaching, many providers are worried about how the changes will impact their bottom line. ICD-10 will be especially difficult for practices whose EMR vendor is not ready, but for the most part if you have the right partners to support you through ICD-10 you will find that with a little preparation things probably will not be so bad. We're already testing and training with our customers in both 5010 and non-standard formats and encouraging them to test with payers as well. In regard to revenue, we do not expect any big immediate jump in denials, and we expect changes to code edits to emerge more gradually over time. For 2014, revenue cycle professionals need to be vigilant to monitor for denials and underpays carefully and pay close attention to how claims are getting paid. Payers will likely experience higher error rates as they digest both ICD-10/5010 and the new plans and new members coming into the market under the ACA, so provider organizations should not be surprised to see more late pays and more incorrect denials and underpays. Again, it will be critical to have good vendor partnerships to automate that vigilance and to help flag and fix mistakes.

Advancing new payment models

Another key takeaway for your 2014 strategy is to look at how new payment models will impact your revenue cycle. As our industry moves into the era of accountable care--whether a bundled payment model, capitation model, or a combination of both--provider organizations are now at risk for not being paid for all of the care that they've provided. This is not only an opportunity to improve the quality of care that you provide, but it's also an opportunity to become more efficient and get paid more for the care that you've provided--especially if your organization is working hard to reduce costly readmissions and ensuring processes are covering the total cost of treatment. The trickiest part for revenue cycle professionals is trying to figure out how to handle the payment structure in an ACO--how to distribute payments appropriately and how to determine which processes are most cost effective. This leads us into an entirely new way of processing, reconciling, and distributing payments. We have been doing a very similar version of that process with our integrated system customers, and it does require a very different orientation around the billing and reimbursement process.

Anticipating eligibility confusion through health insurance exchanges

Finally, the months ahead will be a reality check for your organization's eligibility verification process. As we are getting ready for the health insurance exchanges and the influx of newly insured patients, there is going to be a period of confusion. During this time of chaos, it's important to have the most flexible and reliable processes and technology in place to ensure you have accurate E&B information, since there is likely going to be a lot of mistakes made as payers adjust to the influx of new plans and members.

2013 was definitely one of those "interesting" years--and 2014 looks to be at least as interesting. As you and your organization look ahead, the changes will be more of a blessing than a curse, as long as you pay close attention to key trends and take away the lessons you've learned.

Jim Lacy is CFO and general counsel, ZirMed. For more on ZirMed:
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Title Annotation:Revenue Cycle Management; international classification of diseases; hyperimmunoglobulin E syndrome
Author:Lacy, Jim
Publication:Health Management Technology
Geographic Code:1USA
Date:Dec 1, 2013
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