ICD-10 Issue Preparation and Contingency Planning for Health Insurance Payers

Transcription

1 ICD-10 Issue Preparation and Contingency Planning for Health Insurance Payers Developed by the HIMSS ICD-10 Contingency Planning Work Group, under the HIMSS ICD-10 Task Force October 2014

2 Introduction This document is designed to assist the health insurance payer by identifying actions they may wish to take between now and 10/01/15 to navigate unforeseen or unplanned business disruptions during the ICD-10 transition. Also included are anticipated issues that may be encountered with the ICD-10 transition and suggested responses to mitigate the impact of these challenges post 10/01/15. This audience likely shares the following traits: Has in-house staff familiar with ICD-9 and training for ICD-10 Has a funded ICD-10 program in process for 2 years or more Utilizes several clearinghouses, multiple hospital and physician providers Is aware of the potential operational and revenue impact of ICD-10 and is developing strategies for dealing with those impacts

3 Step 1: Recognize the Signs of Not Being ICD-10 Ready Your organization cannot process transactions with ICD-10 Your organization can process ICD-10 claims, but the payment is not correct due to inaccurate rules and triggers for medical necessity, evaluations and referrals based on ICD-10 codes Your organization relies on crosswalks to convert submitted ICD-10 codes backwards to ICD-9 codes for payment Your organization has not completed extensive testing of business and system modifications internally and with trading partners

4 Step 2: Understand the Potential Consequences of Not Being ICD-10 Ready Severe disruption in the revenue cycle Extended claims payment cycles leading to prompt pay penalties and/or network disruptions Increased operational costs due to rework and elongated transaction cycle times Reduced productivity due to correcting/disputing rejected claims Member/patient frustration over delayed or inaccurate reimbursements Inaccurate quality and financial reporting Inaccurate claim reimbursement, denied claims, coordination of benefits, or authorization of services Possible delay in patient care

5 Step 3: Take Action NOW to Minimize the Need for Contingencies Identify all your trading partners, assess their progress, and evaluate options for end-to-end partner testing. Consider: Contacting your providers and encourage their participation in end-toend partner testing. Determining the project status of clearinghouses and key providers in your network, such as physician practices, labs, etc. Contacting your regional health information exchange or state ICD-10 collaborative. NOTE: It is likely that the payer will be expected to take a leadership role in the formation of a testing consortium with providers.

6 Step 3: Take Action NOW to Get ICD- 10 Ready (cont d) Develop and follow an implementation roadmap or timeline that includes: Analysis of historic ICD-9 code use to help prioritize the most used, highest value ICD-10 codes needed. Participation on a state, regional or community ICD-10 forum for end-to-end testing. Reporting of key ICD-10 program metrics. Contingency planning with your trading partners. Convert all policies, procedures and systems to ICD-10 (including provider contracts, payer edits, medical necessity triggers, etc.)

7 Step 4: Anticipate operational issues ahead of conversion date and identify potential responses We cannot emphasize strongly enough the importance of planning to ensure the smoothest possible transition to ICD-10. We recognize however, even the most comprehensive planning cannot guarantee 100% success. The following are some examples of operational issues you may experience post 10/1/15 and suggested responses for mitigating their impact on your organization.

8 Issue: Your agency is processing ICD-10 transactions, but claims are pending at a high rate, resulting in payment delays Pre-implementation Activities (Prior to October 1, 2015): 1. Work with your providers to agree on a process for monitoring and responding to increases in pended claims. 2. Participate in end-to-end testing with your providers and determine procedures for resolving differences in coding interpretations. 3. Identify the most frequently used high value DRG codes for your office and ensure that testing with providers includes comparison of reimbursement amounts for these DRGs. Post-implementation Activities (On & After October 1, 2015): 1. Activate the agreed-upon process for resolving issues with affected providers. 2. Determine if there are patterns with pended or rejected claims that would suggest the need for adjustments in business or systems processes.

9 Issue: Your organization tested ICD-10 transactions with your providers, but you are experiencing unexpected system processing delays with your trading partners Pre-implementation Activities: 1. Ensure adequate time for end-to-end testing of ICD-10 claim files prior to the conversion deadline. 2. Test with as many providers in your networks as is feasible. Post-implementation Activities: 1. Communicate with trading partners to identify the cause of the delay, along with the expected resolution timeframe. 2. Determine if manual workarounds are required, such as paper-based claim processing.

10 Issue: Executive management wants to know the overall status of the conversion Pre-implementation Activities: 1. Identify key metrics with your provider network to track overall conversion status. 2. Agree to and build a reporting mechanism. Post-implementation Activities: 1. Be proactive in providing information to executive management. 2. Request updates of key metrics from your provider network to add to your payer metrics reporting.

11 Issue: You are experiencing unusual patterns in submission of codes (i.e. large number of unspecified codes, unexplained DRG patterns, etc.) Pre-implementation Activities: 1. Negotiate with your providers for contract provisions that help to protect against unexpected revenue swings. 2. Provide education on appropriate ICD-10 coding and policies. Post-implementation Activities: 1. Increase audits of ICD-10 transactions against clinical documentation focusing on high-risk DRG categories. 2. Establish financial impact reviews of ICD-10 reimbursements with your providers.

12 Closing Thoughts: Augment staff to support the expected increase of provider and member calls as well as the unintended consequences of translation errors, medical necessity, medical policy, contract changes, and system problems. Assess your organization s priorities, strengths/weaknesses. Tailor your contingency plan to mitigate risk.

13 Additional Resources HIMSS ICD-10 PlayBook Vital Vendors Readiness Tool (contains list of vendors who have selfreported ICD-10 readiness) ICD-10 - Centers for Medicare & Medicaid Services Includes Timelines and checklists for Large Practices, Small and Medium Practices, Small Hospitals, Payers HIMSS National Pilot Program AAPC AHA American Hospital Association Resources on line State and local organizations AMA American Medical Association ICD-10 Code Set Standards and Information State and local organizations AHIMA American Health Information Management Association ICD-10 Web Page State and local organizations ICD-10-CM/PCS Transition Planning and Preparation Checklist Role Based training model ICD-10 Summits Online ICD-9-CM to ICD-10-CM Code Translator Tools WEDI -Workgroup for Electronic Data Interchange Document on metrics ICD-10 Workgroup CDC Centers for Disease Control and Prevention CDC ICD-10 Transition Resources MGMA Medical Group Management Association ICD-10 resources for physician practices HIMSS disclaimer: The above listing is a starting point to the endless supply of ICD-10 resources available to you. HIMSS encourages the viewer to research other ICD-10 resources in addition to this list.

14 Thank you to the HIMSS ICD-10 Contingency Planning Work Group Updated October 2014 by: Ann Chenoweth, MBA, RHIA, Senior Director, Industry Relations 3M HIS John Elie Senior Program Manager, Healthcare Inergex Stanley Nachimson Principal Nachimson Advisors First edition created February 2014 by: Work Group Chair: John Elie, Work Group Chair Sr Program Manager, Healthcare Inergex John Fricke Vice President, Business Development IdentaZone Nancy Stetson, RN, PMP, CPHIMS, FHIMSS Work Group Co-Chair: Adriana van der Graaf, MBA, RHIA, CHP, CCS, AHIMA Approved ICD-10 CM/PCS Trainer Associate Director, Healthcare Navigant Diane Kolodinsky, MS,RHIA Director, Financial Systems Chester County Hospital Penny Osmon Bahr Director Avastone Health Solutions Stanley Nachimson Principal Nachimson Advisors