HFMA WEBINAR. Sponsored By: A 360-Degree Perspective on Best Practices for ICD-10 Readiness

Transcription

1 HFMA WEBINAR Sponsored By: A 360-Degree Perspective on Best Practices for ICD-10 Readiness Date: Wednesday, June 3, 2015 Time: 2:00 3:00 p.m. Central (12:00 1:00 pm Pacific/1:00 2:00 pm Mountain/3:00 4:00 pm Eastern) Follow this link (or paste it into a browser) to connect: Please log in 10 minutes early and test your computer connection: Enter platform where it says guest type in your full name first and last name only it is very important especially if you need CPE credit so that your attendance is accounted for You will Not be using your telephone, but will hear the audio via your computer speaker Online live seminars are broadcast over the web via Adobe Connect. You'll need a computer with a browser, Adobe Flash Player 11.2, and Internet connection. Test your connection to Adobe Connect: Login issues to check first: Are you connected to the Internet? Disable popup blocker software. Clear the browser's cache. Try connecting from another computer. Are you accessing the correct URL? Audio Issues: Close all Microsoft Applications, especially Outlook and Messenger. Having Outlook open absorbs almost 50% of the bandwidth which may cause intermittent audio interruptions. If you have questions regarding registration or connection please call HFMA Member Services at ( , ext 2). CPE Information: To receive CPE Credits for this webinar you must participate in online polling during the webinar and complete the online program evaluation within 2 working days. After 2 working days online programs will be inactive and you will not receive CPE Credit. The URL below will take you to our on-line evaluation form. You will need to enter your HFMA I.D. # (found in your confirmation ) You will also need to enter this Meeting Code: 15AT35 URL: You may also connect directly from the last slide of the live webinar Your comments are very important and enable us to bring you the highest quality Programs! To review your CPE information, please visit the HFMA web site at log into your member profile, and retrieve all CPE information (by date) within your "CPE Center.

2 Sponsored By: ICD-10 Collaborative Testing Approach, Results and Lessons Learned Tuesday - June 3, 2015 (12:00 1:00 pm Pacific/1:00 2:00 pm Mountain/2:00 3:00 p.m. Central/3:00 4:00 pm Eastern) Mike Denison, Sr. Director ICD-10, Emdeon Nicole Cohen, Project Lead, Mount Sinai Health System Brian Parkany, Sr. Director ICD-10, Aetna A 360 Degree Perspective on Best Practices for ICD-10 Readiness from Emdeon, Aetna, and Mount Sinai

3 Your guides today Mike Denison, Senior Director, Regulatory Compliance Programs, Emdeon Mike has worked in various leadership capacities in IT, Operations and Product Management across several sectors within the US healthcare market including lab, hospital, health plan and clearinghouse exchange. Mike has over 30 years of experience in administrative healthcare services and has been with Emdeon for 17 years. He is an accredited Project Management Professional (PMP) and served on the local Project Management Institute (PMI) chapter board of directors for 4 years. Brian Parkany, Senior Director, Strategic Programs, Aetna Brian is a Senior Director for Aetna s ICD-10 Program. In this role, he s led Aetna s ICD-10 Collaborative Testing. He is also responsible for ensuring ICD-10 compliance for Aetna s Network & Provider Contracting and Informatics business areas. Prior to taking this role, he was a consultant with Towers Watson. Before that, he worked in various Operations and Business Intelligence leadership roles at Aetna. He has a Bachelor s degree in Health Systems Management from the University of Connecticut along with an Associate in Risk Management. He has been with Aetna since Nicole Cohen, Project Manager, Information Technology, Mount Sinai Health System With 15 years experience in healthcare administration, IT, and project management, Nicole has led major change initiatives including laboratory automation projects, EHR implementations, and has been managing the revenue cycle-related workstreams of MSHS s ICD-10 transition project since Nicole graduated from the University of Pennsylvania and holds certifications in Change Leadership from Cornell University, Lean Healthcare Methodology from the University of Michigan, and is accredited in Accelerating Implementation Methodology by the IMA (Implementation Management Associates). 2

4 Discussion Overall approach Results Clearinghouse best practices Payer best practices Provider best practices 3

5 Objectives For Testing Providers and Software Vendors want to test with Clearinghouses Demonstrate their ability to generate syntactically correct ICD-10 coded claims Determine if ICD-10 coded claims will pass product and clearinghouse edits Providers want to test with Payers Identify, evaluate, and collaboratively review variances in testing outcomes Minimize the risk of rejections, denials, delays, and cash flow disruptions Payers want to test with Providers Utilize provider coded test claims for payer system and application regression testing Gain visibility into provider ICD-10 code assignments for specific clinical scenarios 4

6 ICD-10 Participant Roles The transition to ICD-10 is data content specific. Each participant plays a role in the successful transition to ICD-10. Vendor systems and applications must be enabled & deployed to support ICD-10 content Provider point of care clinical documentation and training required to appropriately code transactions Payer policies and contracts drive operational & payment outcome Clearinghouse validation guidance facilitates the successful delivery of healthcare transactions containing ICD-10, but cannot map to/from ICD-9 & 10 5

7 Collaborative Approach Clearinghouses have assisted in facilitating the exchange of ICD-10 coded test transactions between Providers and Payers ICD-10 Testing Challenges Labor intensive and a manual process Variations in testing workflows, environments and capabilities between participants Coordination and workflow challenges Variance in Approach to Testing Timing and participation limitations Test criteria, requirement, and feedback inconsistencies 6

8 Intelligent Healthcare Network Vendor systems and applications must be enabled & deployed to support ICD-10 content Provider point of care clinical documentation and training required to appropriately code transactions Payer policies and contracts drive operational & payment outcome Clearinghouse validation guidance facilitates the successful delivery of healthcare transactions containing ICD-10, but cannot map to/from ICD-9 & 10 7

9 Testing Approach Provider collaborates with Payer to determine appropriate test claim data Provider Testing Provider sends ICD-10 test claims for validation Claims sent to Clearinghouse, standard clearinghouse reports returned 7x24x365 using existing comm, identifiers, clearinghouse setup Clearinghous e stores accepted ICD-10 test claims Payer utilizes ICD-10 test claims for testing purposes Clearinghouse creates ICD-10 claims/files for Payer testing Payer requests ICD-10 test claims Self-service process Payer Testing Payer collaborates with Provider to communicate appropriate payer feedback 9

10 Trading Partner Claim Testing 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 - Submitter ICD-10 Test Claims Total Testing participation remains low vs. prod volume 21% of submitter orgs have submitted ICD-10 coded test claims representing 77% of inbound volume. 23% of Payer LOBs have received provider sourced ICD-10 test claims Payer Test File Requests Payer Delivered Test Claims Total Total 10

11 Client Outreach and Communications Submitter Surveys Q4 2012, 13, 14 Payer Surveys Q4 2012, 13, 14 Surveys Communication! Communication! Webinars Thought Leadership Mar Employee May 2013 Payer / Partner Apr Partner ICD -10 Readiness and commitment Jun Provider Nov Payer Mar Joint Client HIPPA Simplified - ICD -10 READINESS ICD-10 Program Playbook White Paper Best Practices for Transitioning to ICD-10 Regulatory Update & Timeline 11

12 Lessons Learned ICD-10 Testing Guidelines Testing with Purpose Change Management Cost & Commitment Document Findings / Outcome Publish Findings and Outcome Mutually established and well defined ICD-10 testing charters are required to establish clearly defined requirements, objectives, and scope of testing engagements. Specific objectives with defined measurements of success and expected outcomes. Conducted per the documented process with changes clearly communicated and accepted. Significant costs and commitments from all parties involved and can be very manual requiring significant collaboration, communication, and coordination between all parties participating. Participating organizations should convene at the end of each testing cycle to discuss findings and formally document outcome. Not all providers will be able to participate. Payers and Providers should document and share their aggregate results of ICD-10 testing 12

13 Aetna Vendor systems and applications must be enabled & deployed to support ICD-10 content Provider point of care clinical documentation and training required to appropriately code transactions Payer policies and contracts drive operational & payment outcome Clearinghouse validation guidance facilitates the successful delivery of healthcare transactions containing ICD-10, but cannot map to/from ICD-9 & 10 13

14 Collaborative approach Learning from 5010 experience shaped robust collaborative testing approach Goal was to simulate the end-to-end production process to the extent possible with the goal of increasing predictability of ICD-10 outcomes in addition to reliability testing Phased testing allowed for increased environmental maturity as provider and vendor preparedness progressed 15

15 Results Across all phases, of the 8,804 inpatient claims processed, a total of 1,462 claims experienced a DRG variance (i.e. ICD-10 DRG was different from the ICD-9 DRG) The majority of this DRG variance was found to be Controllable (~85%) and due to Provider Coding / Test Environment factors After filtering out controllable variance, uncontrollable variance rate for all phases was ~ 2.5% Commercial & Medicare Advantage had similar variance rates Key Aggregate Inpatient Testing Results Key Metrics All Phases Mount Sinai # of Claims Processed 8,804 Claims 502 # of Claims with DRG Variance 1,462 Claims (16.6%) 66 Claims (13.1%) % DRG Weight Change 1.7% Increase 1.0% Increase Key Aggregate Outpatient/Professional Testing Results Only 1 claim demonstrated an uncontrollable variance: two ICD-9 Codes map to the same ICD-10 code where one ICD-9 code was allowed and the other was denied in Aetna s clinical policy rules The remaining 27 variances were caused by provider coding mistakes and test environment issues Gender change between the ICD-9 and ICD-10 claim Submission of Diagnosis or CPT codes not associated to the previously submitted ICD-9 Diagnosis or CPT codes Aetna manual processing errors with the ICD-10 claims Key Metrics Aggregate Professional/Outpatient Metrics Volume/Impact Outpatient Professional Total # of Claims Processed 1,121 Claims 567Claims 1,688 Claims # of Claims with a Variance 15 Claims (1.3%) 13 Claims (2.3%) 28 Claims (1.7%) Sources of Variance Determined by Root Cause Analysis Uncontrollable Variance 0 Claims 1 Claim 1 Claim (< 0.1%) Controllable: Provider Coding Variance 14 Claims 11 Claims 25 Claims (1.5%) Controllable: Test Environment Variance 1 Claim 1 Claim 2 Claims (<0.1%) 16

16 Results 17

17 Lessons Learned - Aetna IP Claims Inpatient testing, the biggest driver of DRG variance was caused by provider coding (e.g. missing diagnosis or procedure codes, incorrect diagnosis or procedure codes, or sequencing issues). This variance driver represented almost 70% of all variance we saw in our collaborative testing. In the time remaining before ICD-10 transition, we encourage hospitals to dual code and compare DRG outcomes to understand the drivers of any variance seen. OP / Professional Claims Outpatient and professional claims were tested to verify consistent application of clinical policies. These claims have shown a very low rate of ICD-9 to ICD-10 variance, most of which have also been determined to be controllable. All Claims Aetna has successfully conducted ICD-10 end-to-end testing of electronic transactions with numerous partners and clearinghouses and has not experienced any issues being able to intake and process claims or return ERAs. In the time remaining before ICD-10 transition, we encourage all providers to ensure their coding / billing systems are ready for ICD-10 and seek to do acceptance testing with their clearinghouse. 18

18 Aetna s approach to ICD-10 communication and education Public website with FAQs Provider newsletters Recorded testing results webinars Industry forums Live provider webinars Provider education website Support mailbox for internal staff 19

19 Mount Sinai Health System Vendor systems and applications must be enabled & deployed to support ICD-10 content Provider point of care clinical documentation and training required to appropriately code transactions Payer policies and contracts drive operational & payment outcome Clearinghouse validation guidance facilitates the successful delivery of healthcare transactions containing ICD-10, but cannot map to/from ICD-9 & 10 20

20 ICD-10 Readiness Our Approach Dual Coding Collaborative Testing Internal Financial Analysis System Testing Chart Reviews 22

21 Multiple Initiatives, Shared Outcomes Chart Reviews Internal Financial Impact Assessment Dual Coding Review of 5,000 charts Review of 3,500 DRG shifts Pre-transition review of approximately 2,000 dualcoded charts Collaborative Testing Approximately 2,000 claims adjudicated in ICD-10 23

22 The Results So Far Uncontrollable Changing codes would not be appropriate Financial risk analysis efforts will be focused here Controllable Coding Issues can be addressed by coder education Controllable Documentation Issues can be addressed through physician education and CDI efforts 24

23 Majority of Impact is Controllable What do we do with that data? Educate Repeat Communicate 25

24 Education Plans Tiered and phased approaches For coding staff: ongoing elearning combined with periodic boot camps for focused training For physicians: combination of general training, specialty-specific training, and a robust peer-topeer education program Critical to have formal structures in place, and for all stakeholders to understand this is an ongoing process that doesn t end on 10/1/

25 Support Education with Strong Organizational Messaging Town Hall Meetings Monthly Physician Champion Newsletter Inside Mount Sinai articles Dedicated ICD-10 Intranet Site Social Media Outreach Electronic Fliers 27

26 What do we do about the Uncontrollable? Prevent Streamline current processes Minimize backlogs Track KPI Continuous monitoring and feedback Have your validation plans and tools in place Respond If you touch ICD-10, you need to know how to spell ICD-10 Make sure feedback loops are well-defined both internal and external 28

27 Lessons Learned Controllable does not equal controlled Plan for the learning curve Manage stakeholder expectations Define expected organizational impacts Expect productivity losses Articulate expected outcomes, both big and small, positive and negative Help stakeholders understand how all the pieces are linked Communicate plans to avoid issues, track changes, and respond to problems Use dual coding outcomes to estimate productivity losses Addressing issues will also take time Have your contingency plans ready in advance Streamline current policies & procedures Minimize any current backlogs now Identify all your contacts (both internal and external) and make sure that lines of communication are open COMMUNICATE Reinforce education on an ongoing basis Remember that the work doesn t end on 10/1/2015 Remind everyone that the work is valuable 29

28 Collaboration beyond 10/1 Vendor systems and applications must be enabled & deployed to support ICD-10 content Provider point of care clinical documentation and training required to appropriately code transactions Payer policies and contracts drive operational & payment outcome Clearinghouse validation guidance facilitates the successful delivery of healthcare transactions containing ICD-10, but cannot map to/from ICD-9 & 10 30

29 Ask the speakers a question Just type your question or comment into the Q&A box on your computer screen. 31

30 To Complete the Program Evaluation The URL below will take you to HFMA on-line evaluation form. You will need to enter your member I.D. # (can be found in your confirmation when you registered) Enter this Meeting Code: 15AT35 URL: Your comments are very important and enables us to bring you the highest quality programs! 32