ICD-10 Testing : Operational Neutrality,Financial Neutrality and Benefit Neutrality

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ICD-10 Testing : As a part of overall ICD-10 testing , don't ignore Operational Neutrality, Financial Neutrality and Benefits Neutrality testing.

Operational Neutrality Testing : ICD-9 claims and its equivalent ICD-10 claims have to operate same way means if ICD-9 claims were denied then its equivalent ICD-10 claims also has to be denied,if ICD-9 claim were processed successfully then its ICD-10 claims have to be processed successfully.

Results of this testing will let you know if ICD-9 claims were processed successfully then why the ICD-10 is not processing successfully. This testing is must for ICD-10 test strategy.

Pull out thousand or ten thousand of  ICD-9 claims that was processed successfully or was denied/error out . Convert that claims to ICD-10 claims ( use some automation to convert ICD-9 claims to ICD-10 claims or manually covert it using the X-walk) and process that and see how these ICD-10 claims are working in your ICD-10 adjudication system  and see where is a problem , there may be payer specific edits that is not updated for ICD-10 claims or your clinical editing software is not working correctly or may be some other issues.

This testing will help you post production issues in advance and save your organization for ICD-10 disaster.

Financial Neutrality Testing : This testing will help you to know if  ICD-9 adjudication system were paying  $ X, are you also paying $ X for ICD-10 claims for the same ICD-9 claims or there are minus or plus in pricing. This testing is must for Financial neutrality of ICD-9 claims and ICD-10 claims.

ICD-9 and ICD-10 coding systems are Financial Neutral means there should not be any payment variation, if you find investigate the cause of variation.

Claims are paid either at claim level like DRG or Case rate or line level like  outpatient visits like  professional claims. Make sure that each line is priced equivalent to ICD-9 claims. Get the allowable amount of each line and compare with ICD-9 and ICD-10 claims. Make sure to compare the allowable amounts and not the benefits amounts( like copay, deductible and co-insurance as this varies for every visits).

Ensure providers contracts that uses ICD-9  diagnosis and procedure codes for pricing get re-mediated for  ICD-10 codes otherwise these claims will never be priced. Not all contracts uses Diagnosis codes/Procedure codes but some providers use Diagnosis codes/Procedure codes as a part of provider contracts and that need to be re-mediated specially check all your networx contracts.

Create some automation script to pull out ICD-9 and ICD-10 claims and compare each service line and see the difference in dollar amount  in spread sheet. If there is any variation investigate the issues. May be provider contract has been changed, Fee schedule   has been changed , your contract terms has been changed from per Diem to Case rate or  DRG pricing has changed orany other issues.

Benefits Neutrality : ICD-10 system has nothing to do with benefits of  health plans so cost sharing between Patient and Health plans has to be 100 % neutral. Copay, deductible , co-insurance , out of pocket maximum has to be neutral.

This is going to be neutral unless your health plans have any components bases on ICD-9 Diagnosis codes and Procedure codes.Generally this is least important out of there neutrality testing. 

Please leave comments if you have any.

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