ICD-10 Lessons Learned and a Look Forward A Tale of Two States

Transcription

1 ICD-10 Lessons Learned and a Look Forward A Tale of Two States September 9, 2013 Kimberly Beckendorf Deloitte Consulting LLP kbeckendorf@deloitte.com Matt Galletta State of Maine, Office of MaineCare Services Matt.W.Galletta@maine.gov Renee Washington Commonwealth of Massachusetts, EOHHS renee.washington@state.ma.us

2 Today s Session Our focus today is on the ICD-10 implementation journeys of MassHealth and MaineCare to date...as well as a look forward. 1. Setting the Story MA and ME At a Glance ICD-10 Implementation Approach 2. Comparing and Contrasting Plots Assess Plan Operationalize Remediate Test 3. Lessons Learned 4. The Final Outcome October 1, 2014 and Beyond 1

3 Setting the Story

4 MA and ME Medicaid At a Glance The MassHealth and MaineCare programs differ in scale, operating models, and technologies. Membership Provider Network MaineCare 340K members About 26% of ME population 7,000 providers MassHealth 1.4M members Nearly 20% of MA population 27,000+ providers Claims Volume 17M claims/year 63M claims/year Program Model Operating Model Core Technology Platform 100% Fee For Service Primary Care Case Management (PCCM) program Fiscal Agent Commercial Off the Shelf Claims Platform and Data Warehouse 65% Managed Care 35% Fee For Service State Operated with Maintenance Vendor Custom Developed Claims Platform and Data Warehouse 3

5 MA and ME Medicaid At a Glance (continued) Reimbursement Mechanisms HHS Agency Relationships Key Service Vendors ICD-10 Project Start MaineCare Inpatient primarily Diagnosis Related Group (DRG) Outpatient primarily Ambulatory Payment Classification (APC) Other Fee schedule Support or interface with 9 State HHS agencies Fiscal Agent Behavioral Health Utilization Management Vendor Pharmacy Benefit Manager Assessment kick-off Feb 2011 Before compliance delay MassHealth Inpatient Standard Payment Amount per Discharge (SPAD), Per Diem, and Percentage Discount Outpatient Payment Amount Per Episode (PAPE) for non-lab services Other Fee Schedule Support or interface with 7 Commonwealth HHS agencies 18 Managed Care Entities (MCEs) Customer Service Center IT Maintenance Assessment kick-off Dec 2012 After compliance delay 4

6 ICD-10 Implementation Approach Both MassHealth and MaineCare are following Deloitte s six-phase ICD-10 implementation approach. 5

7 Comparing and Contrasting Journeys

8 Impact Assessment MaineCare MaineCare s MITA-aligned assessment revealed the greatest impacts in Operations and Program Management and supporting systems. Process People Key Impact Assessment Findings Technology 315 business process impacts identified 493 technology impacts identified 230 staff must be trained across levels 18 in-flight projects, of which 10 projects are impacted by ICD-10 7

9 Impact Assessment MassHealth MassHealth s Impact Assessment identified impacts of the ICD-10 transition across people, process, and technology dimensions and provided broad insight into required changes. Key Business and IT Impact Assessment Findings 164 documents and processes impacted 199 technology artifacts from different systems impacted 425 staff must be trained across levels 36 in-flight projects, of which 17 projects are impacted by ICD-10 8

10 Implementation Planning Both MaineCare s and MassHealth s solution approach is to support ICD-9 or ICD-10 processing based on date of service or discharge. Categories MaineCare MassHealth Implementation Workthreads 7 core business workthreads 4 technology workthreads 5 core business workthreads 9 technology workthreads Code Mapping, Financial Analysis, Project Management, Training, and Communications Timeline Initially Jan 2012 Dec 2013 Currently Oct 2012 Jul 2015 Project Management and Governance Common Common May 2013 Dec 2014 Weekly ICD-10 project status and issues/action items meetings Monthly steering committee meetings Monthly risk review meetings Fiscal agent on ICD-10 team Scheduled vendor meetings Program office touchpoints Bi-monthly vendor/sister agency forums 9

11 Code Mapping Code mapping was a key undertaking for both MA and ME to develop functionally equivalent maps for impacted areas. Codes were primarily sourced from the MMIS Code Mapping Similarities Key conditions mapped included pregnancy, behavioral health, and trauma chapters Approach included a clinical translation phase by Deloitte s State Health ICD-10 Center of Excellence (CoE) and a functional translation phase with state subject matter experts (SMEs) A common tool, the Edifecs ICD-10 Code Management tool, was used 10

12 Key Code Mapping Differences Code mapping approaches varied based on state needs. Categories MaineCare MassHealth Source of ICD-9 codes Business intent of codes Diagnosis codes Procedure codes Mapping decisions MMIS configuration tables MaineCare policy Clinical concepts in MaineCare Benefit Manual and MMIS configuration tables Clinically translated ~5,700 ICD-9 diagnosis codes Minimal use 5 ICD-9 procedure codes mapped Mapped Third Party Liability codes as ranges Mapped only ICD-9 codes used for driving business decisions MMIS configuration tables Multiple source documents Derived from configuration tables within MMIS Business intent and ICD-9 codes specified on source documents Clinically translated ~11,000 ICD-9 diagnosis codes Significant use ~2,600 ICD-9 procedure codes mapped Mapped Third Party Liability codes natively in ICD-10 Mapping all ICD-9 codes, including those not used for driving business decisions 11

13 Design and Development MaineCare s platform centers around a Commercial-Off-the-Shelf (COTS) product, while MassHealth s core claims platform is custom developed. This key difference drives remediation activities. MaineCare MassHealth Business Remediation Internal and External System Interfaces Business Remediation Publications Data Warehouse (MassHealth) Publications Claims Platform (Fiscal Agent) Data Warehouse (Vendor) Claims Platform (MassHealth) Trading Partner Portals Service Delivery Partners Portals Reports Sister Agencies Focusing on periphery Focusing on core remediation and periphery 12

14 Testing Testing approaches and responsibilities are driven by each state s business model. Categories MaineCare MassHealth Testing Scope State Testing Focus Internal Systems Business Remediation Providers External Vendor Interfaces System Integration Testing (SIT) User Acceptance Testing (UAT) Pilot Testing Internal Systems Business Remediation Providers, Billing Intermediaries, and Clearinghouses Software Vendors Service Delivery Partners Sister Agencies Internal End-to-End Testing (E2E) External Beta Testing External Trading Partner Testing Testing Timeline Pilot Testing: Q External Beta: Q External Trading Partner: Q2 Q

15 Communications Communications assessments were used to build sound communications plans in both MA and ME. Assessment Findings Planned Communications Key Stakeholders Key Vehicles Internal Project Team Members Steering Committees Business Units External Providers/Provider Associations Other HHS Agencies Vendors Internal Newsletters Director s Messages Staff Meetings External Provider Portals Listservs & Banner Messages Provider Forums/Advisory Groups Internal ICD-10 Awareness Monthly Project Status Updates Training Updates External Provider Forum/Association Updates Vendor Forums/Meetings Sister Agency Forums (MA) Monthly Project/Status Updates ICD-10 Webpage ICD-10 Questions box Provider Readiness Survey 14

16 More to Come In Progress Both MA and ME are remediating business processes, conducting financial analyses, and planning workforce training. Workthread Business Remediation Key Activities Reviewing/revising policy and procedure documentation, including provider billing instructions Monitoring policy and coding changes on a monthly, ongoing basis Financial Analysis Training Analyzing ICD-10 financial impact on rate setting and reimbursement processes Identifying potential reimbursement changes to address impacts Defining post-compliance monitoring mechanisms Applying findings from training needs assessment to develop training plan and associated curriculum Training impacted staff through ICD-10 team (ME) or Train-the- Trainer (MA) Leveraging external coding certification training for specified staff 15

17 Lessons Learned

18 Lessons Learned MaineCare and MassHealth Both MaineCare and MassHealth implementation efforts share some common lessons learned. Phase Assess Plan Operationalize Remediate Test Lessons Learned Involve both business and IT SMEs early in the process Create a central repository of impacts, including artifacts, to support downstream remediation and implementation Develop an integrated execution plan including external vendors/agencies to identify dependencies, sequence tasks, and track progress Involve business SMEs, coding specialists, and IT in a single forum to allow capture/validation of business intent for code use Establish a governance process to manage modifications/ongoing updates to codes/descriptions and GEMs to simplify change control Considering contingency scenarios during design allows the business future flexibility to accommodate industry/partner readiness Focus on testing critical scenarios to make the best use of limited resources 17

19 A Look Forward 2014 and Beyond

20 ICD-10: Before Go-Live Planning Go-Live planning should incorporate both contingency and operational readiness. Go-Live Planning Contingency Plan Operational Readiness Plan Focus Area Industry Readiness Technology Partner Readiness Program Management People Process Technology Considerations Develop what if scenarios of actions if key industry stakeholders are not ready Incorporate flexible system design to allow swift modification of date parameters/system edits if required Evaluate process or technology workarounds if key partners are not ready to handle ICD-10 codes Assess readiness indicators on an ongoing basis to monitor the preparedness of business partners, providers, and other HHS agencies Verify availability of sufficiently trained staff Validate readiness of updated processes Confirm ability to handle contingency options Review testing results in relation to strategy/plans to confirm all key testing components are complete 19

21 ICD-10: At Go-Live Monitoring Pre-defined monitoring metrics can establish variance thresholds and associated actions for key areas of exposure. Monitor ICD-10 codes that drive the greatest potential variance in medical costs; e.g., those that may impact reimbursement processes Financial Exposure Operational Exposure 1 2 Technical Exposure Monitor ICD-10 impacts to critical business and operational indicators such as autoadjudication rates and pend/deny/pay metrics across the enterprise 3 Monitor ICD-10 impacts to technical systems, rules, configurations, and internal and external interfaces Monitoring Metric Triggers for Action Levers to Invoke Sample Operational Measures Pend volume changes by ± A % of the preceding year s monthly average volume OR Pend volume changes by X claims 1. Determine root cause of variance; i.e., conditions attributed to the increased pend volume 2. Monitor specific providers for coding patterns 3. Evaluate claims adjuster productivity and address re-training needs, as necessary 20

22 ICD-10: 2014 and Beyond Value realization from ICD-10 should increase over time as experience emerges Beyond 10/1/14 Compliance Date 10/1/15 1 Year of Historical Data ICD-10 Remediation Stage Contingency / Compliance Stage Stage 1 Compliance Stage 2 ICD-10 Remediation Dual Processing ICD-10 Processing Realize Value Operational Efficiencies Use more granular data to improve claims and utilization management functions Pay for Performance Analytics Clinical Health & Wellness Apply enhanced data to administer P4P programs rewarding providers who improve quality and reduce cost Leverage the more granular ICD-10 data to provide analysis, trends, and visibility into utilization, fraud and abuse, predictive modeling, and related areas Improve ability to identify medical trends and measure the effectiveness of medical management programs to improve member care 21

23 Q&A Thanks for joining us for this session!

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