Wednesday, January 16, 2019

The Role of Clearinghouses in the ICD-10 Transition

Practices preparing for the October 1, 2014, ICD-10 deadline are looking for resources and organizations that can help them make a smooth transition. It is important to know that while clearinghouses can help, they cannot provide the same level of support for the ICD-10 transition as they did for the Version 5010 upgrade. ICD-10 describes a medical diagnosis or hospital inpatient procedure and must be selected by the provider or a resource designated by the provider as their coder, and is based on clinical documentation.
During the change from Version 4010 to Version 5010, clearinghouses provided support to many providers by converting claims from Version 4010 to Version 5010 format. For ICD-10, clearinghouses can help by:

• Identifying problems that lead to claims being rejected
• Providing guidance about how to fix a rejected claim (e.g., the provider needs to include more or different data)

Clearinghouses cannot, however, help you identify which ICD-10 codes to use unless they offer coding services. Because ICD-10 codes are more specific, and one ICD-9 code may have several corresponding ICD-10 codes, selecting the appropriate ICD-10 code requires medical knowledge and familiarity with the specific clinical event.
While some clearinghouses may offer third-party billing/coding services, many do not. And even third-party billers cannot translate ICD-9 to ICD-10 codes unless they also have the detailed clinical documentation required to select the correct ICD-10 code.
As you prepare for the October 1, 2014, ICD-10 deadline, clearinghouses are a good resource for testing that your ICD-10 claims can be processed—and for identifying and helping to remedy any problems with your test ICD-10 claims.

Keep Up to Date on ICD-10
Visit the CMS ICD-10 website for the latest news and resources to help you prepare for the October 1, 2014, deadline. Sign up for CMS ICD-10 Industry Email Updates and follow us on Twitter.


Health Care Reform 2014 Marks a New Era

Starting in 2014, Americans must have minimum essential coverage or pay a tax penalty.  Options for coverage include insurance purchased through the individual market, a public exchange, a government program or an employer-sponsored program.   Minimum essential coverage includes ambulatory services, emergency services, hospitalization, maternity and newborn care, mental health/substance abuse treatments, prescription drugs, rehabilitative services, laboratory services, preventive/wellness services and pediatric services.

 Changes Coming in 2014

•    Individual Mandate — Everyone (with few exceptions) will be required to have health insurance or pay a penalty.  Penalties start   at $95 per individual, $285 per family, or 1% of income (whichever is greater), and increase in subsequent years


•    Employer Mandate — Employers with 50 or more full-time equivalent employees must offer minimum essential coverage that is affordable (where employee only contributions do not exceed 9.5% of household income)  for at least 95% of its full-time employees or pay a penalty (i.e. play or pay) if one full-time employee goes to an Exchange and receives a premium tax credit.

      If coverage is not offered, penalty is $2,000 multiplied by the number of full-time employees (minus the first 30 employees).

      If coverage is offered but not affordable or does not cover at least 60% of essential benefits, the employer will be assessed $3,000 for each employee receiving a tax credit or $2,000 per full-time employee (the lesser will apply) (excluding the first 30 employees).

•    All states must have a health insurance exchange available for individuals and small business owners to view, compare, and purchase health plans offering minimum essential coverage.

 •    Subsidies — Through the exchange, individuals may qualify for a subsidy in the form of a tax credit if household income is between 100-400% of the federal poverty level.

•    Guaranteed issue — Health insurers must sell coverage to everyone, regardless of pre-existing conditions, and can't charge more based on health or gender.

•    No annual or lifetime limits — Individual and group health plans may not impose annual or lifetime limits.

•    Free preventive care — Plans offering minimum essential coverage must provide several preventive services and screenings at no charge.

 Options for Employers with Less Than 50 Employees

•    Purchase coverage via the SHOP exchange (Small Business Health Option Program) or traditional market.
•    Stop offering coverage and let employees buy an individual plan from the exchange  
•    Provide a defined contribution to assist employees with purchasing coverage.
•    Apply for tax credits to help cover the cost of premiums if the employer:
     Employs 25 or fewer employees.
     Pays annual wages averaging less than $50,000 per full-time equivalent employee.

     Provides at least 50% of the cost of health care coverage for their employees.

 Impact on Individuals and Employers

Individuals, their families, and their employees will have access to health insurance on a broad basis. Employers must assess their options carefully to determine the pros and cons of continuing to provide coverage or allowing employees to access the exchanges.

Although long-term implications are unknown, a number of experts agree reform regulations (i.e., guaranteed issue and mandated level of benefits) may result in increased premiums that will ultimately be passed to employees.

 Learn More

Stay tuned for more health care reform communications, including information on Marsh/Seabury & Smith Insurance Program Management's private health care exchange for members. In the meantime, please call Marsh at 800-842-3761 for more information.
*Marsh and the Association/Society do not provide tax or legal advice.  Please consult with your own advisors to determine how the law’s changes and your decisions impact your personal situation.  

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Public Health Alert: Routine HIV Screening

An Important Message from the Riverside County Health Officer

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