Spending Money and Saving Money: ICD-10 and Other HIT Initiatives Richmond MGMA Mar. 13, 2014

Transcription

1 Spending Money and Saving Money: ICD-10 and Other HIT Initiatives Richmond MGMA Mar. 13, 2014

2 Today s Agenda Administrative Simplification Eligibility EFT/ERA ICD-10 On the horizon 2

3 Patient Eligibility Verification Practices typically: Pick up the phone and attempt to verify eligibility Log on a proprietary plan website Employ the submit claim and cross fingers technique Play chase the patient for the outstanding balances 3

4 Patient Eligibility Verification Operating Rules With new operating rules practices will receive: Health plan name and coverage dates Static financials (co-pay, co-insurance, base deductibles) Benefit-specific and base deductible for individual/family In/out of network variances Remaining deductible amounts All within 20 seconds Next morning if sent in batch mode Challenge: insurance exchange product 90- day grace period 4

5 Electronic Funds Transfer / Electronic Remittance Advice 5

6 EFT Significant Potential for Efficiency Plan compliance, Jan. 1, 2014 Estimates are that: Providers could save ~ $3 per claim Opportunity to: Manual handling of the mail, paper checks, deposits Reassociate payments with remittances Get paid faster Watch out for virtual credit card payments

7 Operating Rules Automates the reassociation of EFTs and ERAs: Requires the health plan to release the EFT payment and ERA within a reasonable timeframe (e.g. 3 days or less) if the provider has enrolled for both transactions; Access to instructions from health plans on how to address late or missing EFTs and ERAs; You receive the key data elements ( trace numbers ) in the two transactions necessary for successful reassociation; and Requires health plans to utilize a uniform set of code combinations for common business scenarios to convey details of the claim denial or payment adjustment (Claim Adjustment Reason Codes/Remittance Advice Remark Codes) to the practice. 7

8 EFT Enrollment ACA standardizes enrollment data and requires online enrollment CAQH now offer UPD EFT enrollment module (caqh.org) Challenge: out of some 1200 health plans, currently only participate (Aetna, Cigna, Wellpoint, CareCentrix, Midwest) 8

9 MGMA EFT/ERA Guide 9

10 ICD-10 10

11 ICD-10 Proving to be one of the biggest challenges faced by industry Each link in the chain must be ready-with no indication that ANY link is ready (incl govt) Implications of provider compliance: high cost, decreased clinician/coder productivity Implications of non-compliance: disrupted $ flow, potential of disrupted patient access to care MGMA most recent survey data, collected late January: 11

12 CMS Administrator-Last Week There are no more delays and the system will go live on Oct. 1, Let's face it guys, we've delayed this several times and it's time to move on. 12

13 Implementation Steps 1. Organize Internally and conduct an Internal Assessment 2. Evaluate Readiness 3. Engage and Train Clinical and Admin Staff 4. Clinical Documentation Improvement 5. Trading Partner Outreach 6. Recognize Costs and Developing Budgets 7. Perform Internal and External Testing 8. Identify Reimbursement Issues and Establish Contingency Plans 13

14 1. Organize ICD-10 Transition Team at The Core Leaders who represent impacted functions from coding to technology; cover all areas identified; develop plan Working groups will be needed to ensure each area gains momentum to execute according to the plan Detailed tasks linked to assessments Status updates to Transition Team Contribute to published updates to employees Develop ICD-10 overview presentation to explain the importance and scope of this regulatory change Action Steps: Establish transition teams and working groups, ensure they meet regularly to maintain momentum (e.g. weekly), providing updates Present ICD-10 overview presentation to employees Publish progress and alerts to employees from teams each month Others HIM Physician Education ICD-10 Transition Team Finance Coding Technology

15 2. Evaluate Readiness Understand The Complete Picture Define your process from the patient encounter to posting payment (or update previous work), careful to recognize: Secondary processes such as denials processing and reporting/bi (ad hoc and standard) Integration points with business associates/partners/payers Key roles in the process that influence coding Systems used to support the process, classifying each system as having: Direct, Indirect, or no impact Action Steps: Prepare simplified process document Review CMS resources made available on their website; other industry resources are also very useful Evaluate and leverage the tools that fit your environment

16 Evaluate Readiness Impact Assessments Infrastructure and process changes will be essential to succeeding in your transition to ICD-10. High level assessment are important, but detailed assessments are key: High level assessment, addressing overall situation for awareness, planning, and aligning teams/groups Productivity analysis, addressing increased complexity Financial analysis (837s), addressing impact of code maps Budget planning, managing the cost of the transition and the ongoing cost increases to the organization Technology not ICD-10 ready, identifying dependencies Action Steps: Complete high level assessment document; use key elements to brief leaders and physicians as needed Complete detailed analyses to drive necessary infrastructure, process, and contract changes Process People Technology

17 3. Engage and Train Staff Engaging Physicians Leverage results from detailed analysis of 837 s Overall impact of program to the practice Specialty-specific challenges identified Physician-specific statistics on mapping, if available Target education materials Provide tools for monitoring and custom mapping Action Steps: Present overview of program with detailed results Explain consequences of non-action, non-compliance Deliver targeted education program Solicit feedback; evaluate potential tools

18 4. CDI-Significant Challenge for Clinical Staff Patient encounter documentation must be sufficient to support: Specificity (i.e., laterality) Granularity (i.e., diabetes) Medical necessity of the code descriptor 18

19 Expected change in difficulty What is the expected change in difficulty to accomplish the following practice activities under ICD-10? Answer Options % of respondents that indicated Somewhat or much more difficult June 2013 Jan Ability to document the patient encounter 89.1% 89.8% Ability of clinician to select appropriate diagnosis code Ability of coding staff to select appropriate diagnosis code Ability to compare new diagnosis data in ICD-10 with previously collected diagnosis data using ICD % 97.6% 92.3% 93.1% 91.7% 87.8% 19

20 Working with your Clinicians: Documentation Assessments Take a broad selection of previously and successfully adjudicated claims (most frequently billed codes) and: Recode for ICD-10 (was the documentation sufficient?) Dual code claims being developed Teaching opportunity Utilize peer-to-peer dialogue Explain ramifications 20

21 Assigning Codes Clinicians have several options: Book Superbill (1 page turns into 10) Computer program Mobile device 21

22 ICD-10 in itunes 22

23 5. Trading Partner Outreach 23

24 Trading Partner Outreach-Software Vendors Ascertain what systems need to be upgraded or replaced. Then ask vendors: Upgrade or replacement? Which version(s) will be upgraded? Costs covered under maintenance agreement? Timeline for installation / testing Hardware upgrades required? Utilize 4010 or 5010? Will software permit both ICD-9/10 codes? Are they offering any training? 24

25 Trading Partner Outreach-Clearinghouses Questions to ask: What ICD-10 services will you provide? What if we are on 4010 (workarounds)? What will be the cost of your services? When can you accept test claims? Will you publish a listing of payer readiness and payer testing schedules? 25

26 6. Recognizing Costs and Budgeting 26

27 Recognizing Costs Primary expenses to budget for: Impact assessment Software/hardware Workflow redesign Staff training Superbill redesign Reduced clinician productivity 27

28 New Cost Estimates Typical Small Practice (3 FTEs) Typical Medium Practice (10 FTEs) Typical Large Practice (100 FTEs) 2008 Estimated Costs 2014 Estimated Costs $83,290 $285,195 $2,728,780 $56,639 - $226,105 $213,364-$824,735 $2,017,151-$8,018,364 28

29 7. Internal and External Testing 29

30 Testing-Internal Complete internal testing to ensure all systems and work processes can function properly with ICD-10 codes Can you create administrative transactions, claim, eligibility requests, prior authorizations, etc.? Can you generate other reports quality, public health, etc.? Is your PMS EHR interface working? What about other practice software that utilize ICD codes (i.e., case management, clinical trials)? Include testing manual processes to see how they will flow with system changes Give yourself sufficient time to fix problems 30

31 Working with Your CH Majority of claims routed through clearinghouses CHs are reporting up to 20% of practices still on 4010 They can help but not solve your ICD-10 issues Without the clinical documentation, the CH cannot assign or cross-walk codes 31

32 Ask Your CH for the Following Reports: List of your top claims: Paid (volume, amount) Rejected (payment policy/documentation) Pended (payment policy/documentation) Where unspecified codes were used Leverage these reports during your CDI exercises 32

33 Testing-External Testing should involve all of the steps a claim goes through for processing Identify who to test with and when they will test If end-to-end testing is done, review the 835 closely to see how the claim processed Did the claim reject or pend? Is the reimbursement what you would have received under ICD-9? Were there any adjustments in the payment? Allow time to fix any issues identified during testing 33

34 Anthem-Testing We are conducting File Validation Testing for providers who are EDI direct submitters. We have chosen TIBCO Validator as our primary testing tool that offers unlimited testing of your EDI HIPAA transactions. This self-guided, web-based processing application is equipped to test file formats and edits as they pertain to ICD-10. To get started, visit our Anthem EDI webpage where you will find the Free On-Line HIPAA Validation Testing link to register for Validator and more information and the guidelines for using the tool. If you are not an EDI direct submitter, you will need to partner with your claims submission vendor (clearinghouse, billing company, etc.) to test with us. 34

35 Anthem Testing End-to-End Test An End-to-End test of our systems and business functions which demonstrates ICD-10 readiness levels both internally and externally launches in 1st quarter The End-to-End test will engage selected providers, hospitals, clinical EMR providers, vendors, data trading partners and others to help ensure we are ready for ICD- 10 across the industry. We will share guidance and learning gained from these tests with you as we prepare for ICD

36 Critical Issues Little industry testing taking place Many software vendors not ready Workers comp remains on ICD-9 Are plans ready? (Edits not getting to clearinghouses.) If no testing, the go live date becomes the testing (a la healthcare.gov) 36

37 Medicare Testing Medicare/Medicaid readiness level unknown First said no testing (MGMA letter) November 2013 announced front-end testing in March (MGMA letter) Just announced end-to-end testing, but Only limited to 500 providers (all types) Won t start until July When will results be published? 37

38 8. Identify Reimbursement Issues and Establish Contingency Plans 38

39 ICD-10 Reimbursement Issues Changes to payers policies Will payers restructure fee schedules based on diagnoses? Will payers change any requirements for reimbursement? Will payers require more attachments /documentation reviews? Release of payer edits to CHs Will they be done in time to test? 39

40 How will Payers Handle Unspecified? Will unspecified be covered? What if payers adopt different policies? Does not guarantee payment? Will they decrease payment? Paid initially then rejected? How can a practice prepare? Ascertain payer policies asap and train admin and clinical staff Limit use 40

41 Contingency Planning 41

42 Overall Readiness Level Please rate your practice s current overall readiness level for ICD- 10 implementation: Answer Options June 2013 Jan Not yet started our implementation 55.4% 38.4% Somewhat ready 33.6% 40.9% Approximately half completed 6.2% 11.3% Made significant progress 4.7% 9.4% Completely finished with our implementation 0.1% 0% 42

43 Contingency Planning-The What Ifs I What if PM is not upgraded? Look at your options for claims submissionsthese could include online portals, dropping to paper, working with a billing service Each will decrease productivity and cash flow and cost you money Look at alternative software What if your RCM team is not ready? Test staff capabilities Limit vacation time around Oct. 1 Look at bringing in extra staff short term 43

44 Contingency Planning-The What Ifs I What if you experience cash flow disruption? Limit spending leading up to compliance date Set aside cash reserves Establish a line of credit (can be problematic) File (ICD-9) claims on time/follow up on pended/rejected claims prior to Oct. 1 Talk to your payers about any safety net actions they will take to pay claims 44

45 What are the Government s Options? 1. Do nothing What are the ramifications? 2. Extend the compliance date Who is opposed? 3. Allow dual use of both ICD-9 and ICD-10 Who claims this can t be done? 4. Relaxed edits Would this apply ONLY to Medicare/Medicaid? 5. Enforcement delay How would this help? 45

46 Critical Take-Aways Be as prepared as possible for ICD-10 Staff buy-in/training is critical Be aggressive with your trading partners Monitor your claims processing and reimbursement closely Focus on codes and payers that make up high volume/high dollar reimbursement Ideal testing will test the entire flow of a claim to the payer and back with a remittance advice Any testing is better than no testing Avoid testing in production after Oct. 1 Expect cash flow interruptions Prepare for the what ifs 46

47 The Near Future for Practices 47

48 Smart Cards and Admin Simp Problems associated with patient matching/patient ID cards Machine readable patient ID cards can improve practice operational efficiency by: Effectively identifying the patient Permitting card-pm system interface thus eliminating rekeying errors leading to claim issues Reduces resubmission and re-adjudication costs for both provider and payer Permitting initiation of real-time insurance eligibility verification and allowing practices to utilize the new 270/271 operating rules Permitting initiation of real-time claim adjudication 48

49 Smart Cards 49

50 Practice Management System Software Problems: Doesn t always allow practice to take advantage of the new standards Brochures and salesmen Identity theft Patient ID cards that lack all utility 50

51 PM Issues AMA-MGMA PMSS Directory We would like a more formal certification process in place ACA plan requirement, ATCB MU process Increased assurance that we can not only meet federal mandates, but truly take advantage of the ACA admin simp opportunities

52 PM Accreditation 52

53 In Summary Significant opportunities to automate your practice Focus on eligibility and EFT as low-hanging fruit Talk to your vendors and CHs about opportunities, plans about compliance Get started on ICD-10 it may be here to stay MU Stage 2 will be tricky-talk to your colleagues/vendors Keep one eye on tomorrow s opportunities Look to MGMA as your trusted partner! 53

54 Questions? Thank You! Robert M. Tennant

55 Resources mgma.org/icd10 55

56 CMS (NGS): Administrative-Simplification/Affordable-Care-Act/End-to-End-Testing.html 56

57 New CMS Resource: 57

58 Recent MGMA Member-Benefit Resources December 2013 February 2014 MGMA/AMA 2014 ACA Exchange Checklist EFT and ERA Guide Requesting payment via EFT sample letter Final 2014 Medicare Physician Fee Schedule Analysis General Medicare Update for 2014 webinar on-demand Updated MGMA/AMA Ordering/Referring Fact Sheet Meaningful Use: Top Member Questions Get the latest in regulatory and legislative news straight from the nation s capital through the Washington Connection, published weekly by our Government Affairs team. 58

59 Visit our website for full pricing information and to explore all of our membership options, including special rates for group memberships. Use the code GAMEM to wave the application fee when you sign up for an annual membership today! 59

60 Thank you! Robert Tennant

61 New Approach to MU Penalties After several MGMA letters CMS announced exemption for the following: 2014 EHR Vendor Issues: The eligible professional s EHR vendor was unable to obtain 2014 certification or The eligible professional was unable to implement meaningful use due to 2014 EHR certification delays. CMS Tipsheet: Guidance/Legislation/EHRIncentivePrograms/Downloads/PaymentAdj_ HardshipExcepTipSheetforEP.pdf 61

62 MU Tips Review closely your current or potential vendor contract for upgrade schedule Carefully review ROI (cost/penalties vs incentives) Pick the right software for your practice, not necessarily the cheapest, or even one that meets MU Be mindful of HIPAA security assessment leading cause of failed MU audits 62

63 Resources MGMA ICD-10 Resources CMS ICD-10 Web Resources

64 64 Resources CDC Web Page (General ICD-10 information) ICD-10-CM files, information and GEMs between ICD-10-CM and ICD-9- CM ICD-10 home page (WHO) NCHS Basic ICD-10-CM information CMS ICD-10-PCS information WEDI ICD-10 Implementation