ICD-10: Business Continuity Contingency Plans. Presenter: D. Keith Hatch, Florida Blue, Consultant, EDI Operational Assessment

Transcription

1 ICD-10: Business Continuity Contingency Plans Presenter: D. Keith Hatch, Florida Blue, Consultant, EDI Operational Assessment

2 Presentation Content Purpose Provide an overview of activities to ensure operational continuity of healthcare services and effectiveness of the industry value-chain, following the October 1, 2014 mandate. Content Scope for contingency planning Why an industry scope? What could impact business continuity? Contingency plans, benefits & consequences Keys to successful contingency planning Questions

3 Scope for Contingency Planning The Industry Value-chain Providers Vendors Provider desktop applications (EMR, EHR, etc ) Billing Systems Clearinghouse Health Plans Members YOU!!!

4 Why an Industry Scope? Billing System E1 Payer / Provider Self-service Applications Patient Services E1 E3 Patient / Plan Member E3 Physician Practice Management Systems E4 Provider Contracted Clearinghouse Processing E5 Payer Contracted Clearinghouse Payer Transaction Adjudication and Business Processes E7 E8 Payer Contracted Clearinghouse Provider Contracted Clearinghouse Processing Practice Management Systems Accounts Receivable Electronic Health Record Application Clearinghouse Subsidiaries or Subcontractors Processing Clearinghouse Subsidiaries or Subcontractors Processing Revenue Cycle Management Application Payer / Provider Self-service Applications E1 E3 Physician s medical record documentation is insufficient to properly code the event. Desktop software has not been updated to HIPAA 5010 / ICD10 version. Physician / staff have not been properly trained on the ICD-10 code. E4 E5 Provider desktop applications revisions have changed the syntactical content or format of the transaction. Clearinghouse edits have not been modified to align with up and downstream application revisions, related to ICD-10. Inconsistent interpretation of compliance guidelines related to situational elements within the standard transaction. E7 E8 Payers have not remediated every business rule, medical coverage guideline, and database within the adjudication systems. Contracts with provider specific agreements based on ICD codes have not been identified.

5 What could impact business continuity? Event Insufficient medical documentation Insufficient ICD-10 code training Out-of-date desktop software Inconsistent application and vendor conversions btw ICD-9 and ICD-10 Incomplete remediation of business rules and medical coverage guidelines. General Impacts: Increased operational costs due to increased rework and transaction cycle times Delayed revenue cycle Potential increase in patient /member financial liability Possible delay in patient care Increased probability of inaccurate claim reimbursement, denied claims, or authorization of services Impact Incomplete or inaccurate coding Increased manual processing Increased rejected transactions Increased volume of held claims for review Inconsistent implementation of contingency plans Increased transaction cycle times Increased reporting and trending complexity

6 INDUSTRY Contingency Plans Contingency Plans Benefits Consequence ICD-10 implementation with DELAYED enforcement. Delay the implementation of ICD-10 Allow for continued direct provider reimbursement for late implementer of ICD-10. More time for industry to implement Delayed claim reimbursement for coordination of benefits (COB) and other payer liability (OPL) claims Increase patient/member balance billing Increased operational cost (dual coding of claims, multiple platform maintenance, etc ) Increased industry cost Delay strategic value of ICD- 10 The presenter does not endorse or promote any of these contingency plans. This deck is to provide the audience with alternatives.

7 PROVIDER Contingency Plans Contingency Plans Benefits Consequence Dual code transactions Consistent revenue cycle Decreased probability of patient balance billing Increased production cost Increased maintenance cost Establish a line of credit Consistent operational funding Increased interest expense Augment clinical documentation and coding staff Decrease or maintain production cycles (effectiveness depends on the knowledge and experience of the staff) Increase administrative cost The presenter does not endorse or promote any of these contingency plans. This deck is to provide the audience with alternatives.

8 VENDOR Contingency Plans Contingency Plans Benefits Consequence ICD-9 to ICD-10 Conversion Applications User compliance with ICD-10 Increased incorrect claim reimbursement Increased inappropriate rejections Increased administrative cost Guarantee Provider Revenue Maintain provider business continuity Possible gain in market share Loss in reserve earning potential Increased bad debt expense The presenter does not endorse or promote any of these contingency plans. This deck is to provide the audience with alternatives.

9 PAYER Contingency Plans Contingency Plans Benefits Consequence Dual-mode. (Processing ICD-9 claims regardless of dates of service) Retain the industry revenue cycle for late adopters Increased operation and maintenance cost Increased maintenance cost Delays industry compliance Increased reporting complexity Augment service area to support transaction issues and calls Maintain or reduce the transaction cycle impacts Reduce the impact to provider revenue cycles and member services Increase operational and training cost Advance budgetary payment Provides funding to sustains medical service operations Reduced the earning potential of deposits Increased collection and reconciliation cost Potential increase in bad debt expense The presenter does not endorse or promote any of these contingency plans. This deck is to provide the audience with alternatives.

10 ICD-10: Business Contingency Plans Keys to successful contingency planning Providers Payers Vendors Testing Adequate and relevant testing to ensure the efficiency and effectiveness of: Internal process and systems are effective; Value-chain processing and application compliance interpretation; and, Remediation of Go-live issues. Based on business process assessments and testing determine the: Operational Appropriate operational staffing models; Application and configuration modifications; Appropriate interpretation of content based compliance issues, and, Training of support staff Financial Reporting Implementation funding requirements to support: Staffing augmentation; Internal / external business continuity agreements; and, System remediation. Accuracy and completeness of internal and external reporting (management and regulatory).

11 ICD-10: Business Continuity Contingency Plan Who needs a contingency plan? YOU!!!

12 ICD-10: Business Continuity Contingency Plan Questions and Discussions Questions and Discussion

13 ICD-10: Business Continuity Contingency Plan Presenter Information Keith Hatch, CRMA, CPA Florida Blue (BCBS of Florida) Consultant, EDI Operational Assessment Phone: (Work) (Cell)