Denials are expected to increase 100-200% during the ICD-10 implementation scheduled for October, 2015.
How many ICD-10 denials will be related to precertification problems? Unfortunately, frequently cited ICD-10 implementation studies have not include any analysis of denial sources. Therefore, it is important to know your current denial rate for denials related to “lack of preauthorization” and “incorrect preauthorization” to have a baseline comparison. Even if your current precertification denial rate is low, you may still benefit from a review of some of the following ICD-10 Precertification Best Practices so that your staff is fully prepared to be the front line defense against ICD-10 precertification denial impact.
First, review how the precertification staff tracks open requests. ICD-10 may result in a delayed response time as payors deploy updated precertification procedures. Your staff should be able to quickly identify any pending precertification request and have a procedure for prompt follow-up to determine status. Precertification staff should also have a letter citing state or accreditation standards applicable to response time frames to keep payers in compliance with professional standards. The Utilization Review Accreditation Commission (URAC) timeframes for an initial utilization decision applicable to prospective review are under 72 hours for urgent care and 15 calender days for non-urgent care. See URAC.org for a summary of other applicable quality utilization review standards.
Second, review how the precertification staff accesses payer communications. ICD-10 implementation will likely involve numerous payer communications which could impact precertification staff. However, often, practices do not have a process for reviewing and distributing payer communications to impacted staff. Assign an ICD-10 team member to be responsible for payer communications review and distribution and for periodic follow-up with impacted staff to make sure critical information was responded to appropriately.
Third, consider discussing an “escalation plan” with precertification to assure prompt management notification of negative impact. Your precertification staff may have many pressures during the ICD-10 implementation. Give extra emphasis to the need for good communication among team members and management. If you do not have tracking policies in place, develop some general guidelines for handling payer non-response and/or questionable denials. Also, emphasis with precertification staff that signs of poor payer performance, such as untimely decision-making and high denial rates, should be tracked and reported to management so that appropriate follow-up with higher level payer contacts can be initiated.
Lastly, if your organization does not routinely schedule peer-to-peer reviews of denial precertification requests, now is a good time to get your care providers involved in this process. Most payer utilization review processes now have protections which require peer-to-peer review of any denied care. However, this additional round of review is not routinely provided unless requested. Since ICD-10 has greater specificity, payers may develop medical necessity edits which could trigger precertification edits for certain care scenarios. Participating in peer reviews of these denials will allow your care providers to discuss the appropriateness of these new edits and also facilitate better understanding on both sides.
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