Business Processes

Successful implementation is not just about reprogramming systems to achieve technical compliance. Payers should view their compliance efforts as a transformational event for improving business processes. Only through a Change Leadership/Business Process Reengineering methodology will payers move their efforts from minimal compliance to competitive advantage.

Business Impacts

The transition to ICD-10 will impact virtually every functional area within a payer. Payers will need to review and update all code driven or dependent applications and interfaces. While the transition occurs, payers will have the opportunity to streamline systems and processes.

For example, consider the following:

• Underwriting will need to reprice services. If priced too low, payers will incur losses. If priced too high, payers may alienate providers and lose members.
• Provider relations will need to negotiate new provider contracts that include new reimbursement structures.
  
• Provider relations will have to work with providers on claims that are not properly coded and rejected on first pass.
• Customer service representatives will have to field increased call volumes from members asking why their claims have not been paid.

Change Leadership/Business Process Reengineering

Payers must instill the need for change from a high level. Only through positive Change Leadership will an organization properly address the business impacts, and only through Business Process Reengineering will payers fully capitalize on the needed changes. An effective approach to Change Leadership/Business Process Reengineering leads to processes that are compliant and that give payers a competitive advantage.