Applying Lessons Learned With 5010 to ICD-10

Transcription

1 Applying Lessons Learned With 5010 to ICD-10 An EDI Vendor Perspective Music City Chapter AAHAM June 21, 2012 Presented by Doug Bilbrey Executive Vice President Sales and Marketing

2 Agenda Who is The SSI Group, Inc.? 5010 Migration: The Experience A Clearinghouse Perspective Report Cards Are In MAC Stats Now What?

3 Who is The SSI Group, Inc.? 24 years in healthcare EDI providing advanced revenue cycle management solutions $700 billion in electronic claims in plus clients nationwide Over 800 direct payer connections Open access for other clearinghouses Industry certifications HFMA Peer Reviewed, CORE/CAQH, EHNAC Industry advocate WEDI, AAHAM, AHIMA, HIMSS, HBMA, NCVHS, CMS, Cooperative Exchange and Nashville Healthcare Council

4 Summary Migration 5010 Timeline

5 Clearinghouse Experience Challenges and Results Challenges Payer testing results not equal production environment Proper utilization of 999 acknowledgments as designed Payer lack of testing strategy or timeline Results Edits: modified or relaxed Resubmission of claims Acknowledgments (999/277) utilization/ inaccuracies result in false acceptance or rejections of claims Response delays due to large volume of inquiries/calls (constraints on payer allocation resources)

6 Medicare Administrative Contractor (MAC) by Jurisdictions File Level Rejections 2011 vs. First 12 Weeks of 2012

7 Medicare Administrative Contractor (MAC) by Jurisdictions Physical File Rejections 2011 vs. First 12 weeks of 2012 by Type (Hospital vs. Physician)

8 All Lines of Business - File Rejections 2011 vs. First 12 weeks of 2012

9 Now What? Continue moving forward - all transactions to 5010 Continue FISS statusing of claims acceptance as a daily business function Review 277 reports and continue contact with your vendors for current information and looking ahead Use 5010 Migration experience as a wake-up call for testing strategies for ICD-10

10 Applying 5010 Lessons to ICD-10 True end-to-end testing is essential Providers will likely be ahead of payers in capabilities With date moved to 10/1/14 procrastination is likely Compacted testing will result in a flawed conversion Revenue will be affected

11 ICD-10 from an EDI Vendor Perspective Systems have been upgraded to accommodate expanded code sets Transport vehicle IE 5010 has been accomplished for the most part Adequate testing time is available Technical aspect of conversion is straightforward Edit / Data ramifications profound While ICD-10 mainly impacts HIM, financial implications could be tremendous

12 Devil is in the Details Payer systems true ICD-10 capabilities Will payers crosswalk ICD-10 to ICD-9 for claim adjudication? If a crosswalk is utilized, how will the remittances be affected? Contract management systems Providers capabilities Payer fee schedules Decision support systems ICD-9 / ICD-10 capabilities Hospital information system vendors Updates / upgrades related to ICD-10

13 Devil is in the Details (continued) Training / education needs Utilization of ICD-9 codes Corresponding ICD-10 codes Revenue cycle vendor readiness Updates / upgrade plans related to ICD-10 Testing Internal testing External testing

14 Industry Viewpoint Institutional providers generally want to keep the 10/1/13 date Significant efforts and cost already expended Why go through the challenges of 5010 if ICD-10 is going to be delayed Professional provider organizations do not want the conversion ICD-10 to ever happen No real benefit Some payers concur with institutional providers Many industry experts believe the 10/1/14 date will be changed Conversion to ICD-10 will make the 5010 conversion look like a walk in the park

15 Keys to Success Industry needs to push for absolution on date Regardless of date Be it 10/1/14, 10/1/15 or any date Payer edits Requirements need to be established Date expectations Communication to providers and EDI vendors Full end to end testing capabilities Providers, vendors, payers Rigid timeline for testing Published Accountability

16 Recommendations Internal gap analysis Systems Staffing Education Contingency plans Challenge your vendors ICD-10 capabilities Plans / availability of updates or upgrades Stay plugged in CMS, AHIMA, WEDI, AAHAM, HFMA

17 Recommendations (continued) Analytics and reporting capabilities Pre ICD-10 Utilization history Payment history Trends Post ICD-10 Complete and accurate coding Maximize revenue opportunities Don t leave money on the table Payment monitoring Actual to expected Denial avoidance and management Plan for an interruption in cash flow Up to two years Have access to reserve funds

18 Closing Comments Conversion will be most significant change in decades Since the advent of EDI Do not alter or reduce efforts based on delay New and enlightening tools from vendors Assessment Monitoring Reporting Budget for New Tools Implement Tools as early as possible

19 Thank You Doug Bilbrey (800) X1108