HSMN has taken note of a Washington Post Opinion article written by Newt Gingrich and Tom Daschle in which they advocate using the provisions in Section 1332 of the Affordable Care Act. In essence this section creates a process for generating “State Innovation Waivers. These are limited but allow States to begin to experiment so long as everything is budget neutral and that the basics of the Affordable Care act remain intact. Especially those related to “Pre-existing conditions.

Many of our clients have struggled with the changes required by the Affordable Care act as have large insurance companies. As a Revenue Cycle Management company our perspective is at ground level. How are the data in reporting that would allow States to receive a Waiver? Has the physician documentation passed the test of the ICD-10 transition? What training have the Medical staff received that would allow them to understand the vast differences in ICD-10 that require a specificity in documenting that exceeds anything that has ever existed?

How are the coders doing not only with the diagnostic portion of the transition but also with the Procedure coding which requires knowledge and critical thinking skills?

What are the root causes of the denials from Claims submitted? Have those data been analyzed for root causes by clinical discipline? If not what Mr. Gingrich and Dascle propose in their opinion piece will be difficult to implement for the States. In 30 years of advising hospitals and physician practices on each iteration of the DRGs, APC’s and those changes in Physician Billing, our clients are telling us to help them review denials, the work Queues accumulating because of the implementation of Enterprise Wide Systems, ICD-10 and the Affordable care act. We would advise that a compromise may be the likeliest solution Congress may attempt during this year but it is the data set that are the underpinning of reimbursement. We are advising our clients to look carefully at the data by going to the sources. Physician, Documentation, Coding practices, reviewing denial data and relooking at the Revenue Cycle Structure in depth.