Decisions That Will Impact ICD-10 Implementation

Transcription

1 Decisions That Will Impact ICD-10 Implementation The following document highlights the types of business decisions that all organizations should consider as they plan for ICD-10 Implementation. The major decisions to be made during the ICD-10 implementation are: A) Costs Training and education of the staff who will be using these codes Updating the existing IT systems Documentation Existing business process analysis, which takes into account coverage, payer contracts and other expenses Possibility of disruption in the cash fl ow No decision is in place at this time. Training: Multiple avenues are available. A decision is needed to determine as to which course of action will be taken; recognizing that multiple courses of action may be appropriate moving forward. Updating existing IT systems: This is very Vendor driven in terms of what is the current release installed at the Client and what release is needed to be ICD-10 compliant (several vendors do not know at this time). This will be further defi ned and accounted for in terms of both direction and overall scheduling. Documentation: This is an on-going issue and may prove to be the single most costly activity of the ICD-10 migration. It is dependent on many factors, such as Vendor readiness, Vendor requirements and in-house utilization. Business Processes: See documentation Disruption of cash fl ow: This is predominantly a problem for the Provider/Institution; however, you, the Payer, needs to be cognizant of this issue, because is a single Provider encounters a large number of Claim submittal errors, the problem could become yours as well in terms of providing work-a-rounds or other activities related to reimbursement for services rendered. This must be monitored going forward with updates being provided on a recurring basis. Alternatives must be explored and presented as possible solutions to prepare for, especially as it relates to disruption of cash fl ow ManpowerGroup. All rights reserved.

2 B) Planning a Phased Transition by Application/Facility Provides for more control Builds a better understanding of the new system by the staff Although no decision is in place at this time, it is prudent to state that the roll-out of ICD-10 migration results will be handled as a phased in transition by application/facility. The issues will center around the readiness of the Client s Provider community and their ability to do pre-testing with you prior to go-live in October 2013 C) Planning and Oversight How will the Client organize the implementation, manage resources, govern projects, track attainment of ICD-10 benefi ts & communicate decisions With the decision to initiate the ICD-10 migration plan as a live project, this will be covered in the initial days of the ICD-10 Implementation Project. The very fi rst phase, at the get go, will establish the tracking and other governess issues associated with the many applications/projects with the ICD-10 migration. The key is to establish consistency of reporting and tracking progress related to the ICD-10 implementation. D) Mapping Strategy Should the Client pursue an upgrade strategy or a crosswalk strategy How should the Client handle/address historical data The Client should at the very fi rst steering committee meeting make the decision that they would pursue the ICD-10 Migration effort as a full conversion of diagnosis and procedure codes from its ICD-9 values and relationships to the ICD-10 equivalence or otherwise. Historic data, such as that found in the Enterprise Data Warehouse (EDW) or Electronic Medical Record (EMR) should not be converted to ICD-10 values and description. Historic data should not be converted for the following reasons: The converted data would not be meaningful and may contain too many exceptions. The effort to convert the data would be extensive with minimum gain of knowledge or information ManpowerGroup. All rights reserved.

3 Historic tracking of activities would be impeded. Use of historic data, today, is minimal, and when queried, the information obtained is primarily date of service by member with little usage of services rendered. Don t waste the Client s time and expense in translating the historic information. Concentrate on information going forward as to being accurate, to include capturing the data in ICD-10 codes and translations. E) Internal Training & Communications What is the training content & curriculum, delivery strategy (e.g. train the trainer, computer based, or classroom) What is the appropriate timing for the training Training content & curriculum: Multiple avenues are available. A decision will be made to determine which course of action will be taken, recognizing that multiple courses of action may be appropriate moving forward. This delay will allow for additional training material to be made available in the marketplace from which to choose going forward. Timing of Training: Although training is needed early on in this overall implementation of ICD-10 codes, the greater majority of training will not occur until calendar year Short term training will be directed at decision makers and data coders who will participate in the overall conversion from ICD-9 to ICD-10. Whenever possible, the Client should employ the use of Computer Based Training (CBT). Specialized training that requires classroom attendance should be directed at Train-the- Trainer approach. F) External Outreach & Communications How extensive should the Client make its external outreach & communications. The extent that the Client will reach out and communicate with external entities needs to be decided. The basic approach initially is for this outreach and overall communication is to be extended to all known active Vendors and large Providers. Over time, this communication should be expanded to include any Provider, Third Party Administrator (TPA) and/or Clearinghouse to ensure commonality of processing, interpretation and execution in accordance with established adjudication processes ManpowerGroup. All rights reserved.

4 G) Risk Planning and Management Which risks require a response plan in the event of its occurrence What will the Client do if a critical risk occurs A decision on this is required for each risk. Knowing that many of the risks will not have a plan in the event of its occurrence, it would be prudent to establish a plan that would be used as a repeatable process for generating a plan should said risk actually occur. See generic risks for ICD-10 It is an accepted fact that many of the risks will not have a plan in the event of its occurrence; however, those that do not incorporate a plan at its inception should be placed in or have access to a repeatable process for generating a plan should it occur. H) System Release Planning How will the Client manage/track release progress & interdependencies How will ICD-10 changes integrate with existing release cycles & change management processes Manage/Track Release(s): The primary need is to establish a means of identifying and tracking each vendor that we associate our overall business processes with on a normal basis. We then must include other vendors who also play in our space for purposes of transmittals or validation to ensure we are not losing a link or jeopardizing a relationship. Once the overall tracking mechanism is in place, then it must be tracked and updated regularly until ICD-10 implementation is completed successfully. Integration with other release cycles and change management processes: The bottom line here is how good your change management process is. Maybe you have it in place but rarely use it. It will become an integral part of your business during this transition period from ICD-9 to ICD-10. If you are not familiar with the process, reacquaint yourself and be prepared to use it going forward. You currently have 20+ vendors involved in your normal processing cycles. Determine who has the most impact on your daily processes. Further, determine which vendors integrate their data with each other. A question to ask yourself is how customized to your business a given application has become. If you have over-customized processes, this may preclude you from readily accepting upgrades from that vendor. In today s world, the vendor has probably already established a release schedule for normal maintenance and upgrades; however, ICD-10 is an exception that may or may not be incorporated into standard release cycles. Part of the inquiries with our existing and future vendors is to establish the approach anticipated, especially for those vendors who have a low ManpowerGroup. All rights reserved.

5 maintenance and/or minimal upgrades on a schedule basis. Once the overall plan is in place and is being tracked, then a decision may be required to prioritize authorization of the vendor pool for initializing and incorporating upgrades during the ICD-10 implementation process. I) Integrated Process and System Designs How will the Client develop an overall system design that refl ects all system & process interactions. This may require multiple decisions to be made and will require extensive input from IT. This is not necessarily a single decision but may be dependent on applications, current usage and integration into the overall process. For many, ICD-10 implementation will require redesigning the overall architecture as new applications key to the overall process are installed. At the completion of the primary activities associated with the ICD-10 implementation, the overall architecture will come into review. New applications being planned, including known upgrades, will also be melded into the overall detail associated with ICD-10 roll-out. J) End-to-End Testing Strategies Will end-to-end testing extend to external business partners What are the test scenarios How will the Client execute the end-to-end testing Although a decision has not been made relative to end-to-end testing and its related strategies, it is safe to say that this will be part of the objectives during the 2nd and 3rd quarters of Not only should you be doing end-to-end testing, you should also be planning on performing analysis reviews associated with what you paid prior to ICD-10 for various types of claims and what will you be paying after ICD-10 goes live. Edits will be key to acceptance of submittals and their resolution. Appeals, short term, may become more numerous. Failures, short term, may also become more numerous. Extend to external Business Partners. This defi nitely needs to be tested from end-to-end for the following reasons: 1. Incorporation of the overall exchange of data 2. New edits and changes to existing edits 3. New formats between entities ManpowerGroup. All rights reserved.

6 Test Scenarios: Test scenarios will be many and diverse. Test scenarios must address in-house activities as well as external activities. End results must be compared to today s processes to ensure proper dissemination of payments and rejections for cause. Executing end-to-end testing: First, end-to-end testing must be identifi ed for each major trading partner in terms of claim submittals. Next end-to-end testing must be tracked for key reporting functionalities, especially those that are delivered external to your organization. Roll-up reporting and data sharing also need to be compared to existing reports depicting ICD-9 codes and their roll-ups. As an organization progresses with its ICD-10 planning and remediation, a set of trends and remediation considerations should be considered/established. ICD-10 Solutions Designs GEMs Reimbursement Clinical Policy Vendors Test Planning Solution decision trends are a combination of dual processing/remediation to support ICD-10 and insulating systems to limit processing to ICD-9 codes. Health plans and providers are using GEM as a baseline for ICD-9/ICD-10 crosswalks; need to analyze the clinical and fi nancial impacts of using the maps. Health plans may plan to update existing clinical policies to include ICD-10/9 codes or may plan to update existing policies to ICD-10 only. Health plans are considering vendor consolidation where there are redundant vendors to reduce ICD-10 remediation costs and overall vendor costs. Health plans are realizing that ICD-10 testing will be invasive and planning needs to begin earlier than traditional large scale programs. Key considerations include: role and responsibilities of IT testing versus business testing, partnering with vendors for testing and determining how to manufacture test data. For more information, contact healthcare@experis.com. Experis is the global leader in professional resourcing and project-based solutions. Our healthcare focus leverages the expertise of the entire Experis organization, bringing solutions to the payer, provider and pharmaceutical sectors. Experis is a dedicated business unit of ManpowerGroup ManpowerGroup. All rights reserved.