ICD-10 and Your Management Care Contract: Hold Harmless or Hold Accountable?

Your ICD-10 preparation checklist seems to be growing, right?
Now, stories are beginning to surface that some healthcare organization are being asked to sign off on hold harmless terms related to the upcoming coding overhaul.

Healthcare Finance News ran a story this month stating that health entities are negotiating ICD-10 hold-harmless clauses. Victoria Vance, an attorney with Tucker Ellis LLP in Cleveland, was quoted as having seen several healthcare organizations and vendor companies that are developing hold harmless clauses in their contracts to mutually indemnify each other.

The article cited another attorney, Sarah E. Swank, an attorney with Ober Kaler in Washington D.C., who cautioned that such clauses require careful review of who is being indemnified and for what actions. She also said that contractual representation and warranties, dispute resolutions terms, insurance and limitation of liability provisions could all be applicable in a ICD-10-gone-wrong scenario.

This type of contract review seems most applicable to intermediary vendors who create and/or submit bills on the provider organization’s behalf and do not want to be on the hook for any payer’s ICD-10 processing problems. But what about the payer contracts? Do we need to look at payer contract terms to make sure there is some accountability for ICD-10 implementation?

One piece of practical negotiating advice would be to use ICD-10 as a reason to strengthen both your payer timely filing, claim resubmission and refund/overpayment provisions. Concentrating on improving these clauses can have a much greater impact to your overall claim throughput and financial health. An added benefit of strengthening these processing-related clauses is that enforcement may be conducted via the appeal process rather than litigation.

The American Medical Association recommends that any managed care contract be reviewed for the following timely payment and offset provisions:

Does the MCO have an obligation to pay you promptly?

  • Does the contract include a specific payment time period, and does the MCO agree to pay interest if it delays payment beyond that time period? Many states have laws that require prompt payment of claims.
  • If your state has a prompt payment law or fair business practice act, does the contract comply with the time frames and interest penalties and other claims processing and payment provisions?

Does the contract give the MCO the right to unilaterally “offset” alleged “overpayments” from amounts otherwise due?

  • If so, does the contract require the MCO to explain such offsets to the physician? Is there a mechanism for the physician to appeal offsets? Does the contract limit the time frame for these payment offsets?
  • Many MCO’s conduct retrospective audits of physician practices several years after services are rendered and then either demand return of sums allegedly “overpaid” or automatically deduct payment without explanation to physicians. Source : http://www.ama-assn.org/resources/doc/psa/15questions.pdf

Appeal Solutions has letters citing each state’s timely payment provision. These letters are highly effective with appealing lack of timely filing if the healthcare provider also has negotiating contract language which mimics state law.

Further, overpayment issues may arise during ICD-10 implementation. An organization should be protected against overly late refund/offset actions and providers should have the right to appeal such decisions. We have a number of coding appeal letters which will likely be very useful in demanding review of a unfavorable coding decision which may result from ICD-10 payer interpretation. We also have a letter to use to initiate renegotiation with managed care payers.

Leave A Response

* Denotes Required Field