How can your organization anticipate and prepare for Payer ICD-10 pre-certification performance interruptions? We recommend developing a ICD-10 training program for pre-certification staff focused on Payer Performance Monitoring. Yes, precertification staff need the traditional elements of basic ICD-10 role-based training, However, consider adding the following Payer Performance Monitoring initiatives to your precertification training session:
- Impact assessment review – Pre-certification staff may be impacted by a increase in payer non-response or incorrect precertification denials. Therefore it is time to assess submission tracking and how staff is alerted to outstanding requests. Review with pre-certification staff how pre-certifications are tracked to insure that tracking resources are available and used correctly. Provide information on any escalation policy related to payer readiness issues.
- Payer updates – Review how precertification staff obtains any information related to payer updates to the payer precertification processes. Prepare precertification staff for the possibility that payers may update procedures to a number of ways including requiring diagnoses codes and changing medical necessity requirements.
- Communication plan – Precertification staff should be oriented to the ICD-10 communication plan with respect to ICD-10 questions which arise during implementation and what types of payer issues to communicate to management. Staff should be prepared to provide ongoing assessment of payer readiness during the ICD-10 transition with specific attention to payer response time frames, payer precertification/eligibility technology changes and payer staffing issues due to increased request volume related to ICD-10.
- Precertification appeal letters – Precertification staff should have access to a number of appeal letters to initiate appeals of delayed or inappropriately denied precertification requests. Review the following list with precertification stall to insure that letters are available for these top ICD-10 concerns and ready for use to improve payer compliance:
- Delayed decision appeal – letter addressing carrier failure to respond timely to precertification request (see our attached example)
- Denial disclosure request – letter responding to a precertification denial wherein the denial failed to cite the clinical justification for the denial.
- Incorrect denial – letter addressing what appears to be an incorrect denial such as incorrect information cited in denial letter or failure by carrier to provide adequate clinical review.
Click Precertification Training Checklist and Appeal Letter Samples to get started implementing a Payer Performance Monitoring Training at your organization. Please comment back any questions or ideas about how to make your Payer Performance Monitoring strategy even stronger.
