Top Five Payer Readiness Questions to Ask Your Payer

dr_EHR / February 4, 2016

International Classification of Diseases-Version 10, popularly known as ICD-10 has replaced the previous version on October 1, 2015. The anticipated adoption of the new codes created lots of speculation in the health sector with most medical providers airing concerns about their payments. Each payer has their unique preparations for ICD-10. As an ENT service provider, you should test your payers for payer readiness by asking them these five questions:

Who is my contact person?

Organizations providing health plans are usually big with thousands of clients. They tend to be bureaucratic and will cater for their clients as a group rather than individuals. You do not want to be one of the many clients given answers that are not meaningful. Stand out and ask for a dedicated contact person. This will give you the opportunity to get your questions answered on time and ensure your needs are catered to. Once allocated a contact person, stick to him or her unless you are not satisfied.

Is external testing going to be conducted?

Although the CMS has been stressing the importance of testing the codes, you must ask your payer if external tests are going to be carried out. The answer to this question should be a ‘Yes’. The contractors from CMS are carrying out tests only with a number of payers, not all of them. You want to be sure that your payer is one among those CMS is doing the tests with. If your payer is not part of these chosen business partners, you should shop around for another payer and contact the CMS on what options you may have.

When will you start using ICD-10?

You should be sure of the exact dates when each of your payers will start using the new ICD-10 codes. Apart from the dates, you should also inquire on the number of claims each payer will be able to accept from you. It is also important to ensure that all your payers are HIPAA Version 5010 compliant as part of their payer readiness. You must also switch to the HIPAA version since the new codes are fully based on it.

Do you support dual processing?

During this transition period, dual processing is vital. Many payers have agreed to accept both ICD-10 and ICD-9 codes during the period. This gives you the time to switch over to HIPAA Version 5010 and also the opportunity to compare the two codes. The dual processing capability will also help you learn and practice using the new codes.

What will happen if the new system fails?

Your business heavily depends on the payments you receive from health plans. Any problem with the system can negatively affect the operation of your clinic or business. Your payers should be ready to offer meaningful communication during such times. By asking this question, you will know the exact process to follow to ensure your business does not suffer.

Apart from these five questions, you should be free to ask your dedicated contact person all the questions you have regarding their payer readiness. Do not hesitate. Online researches can also help you handle some questions that do not need your payers’ stand. Prepare yourself early enough to ensure the ICD-10 codes do not prevent your ENT practice from getting paid.