HCL ICD 10 Transition Services: Helping You Leverage Regulatory Compliance for a Competitive Advantage

Transcription

1 HCL ICD 10 Transition Services: Helping You Leverage Regulatory Compliance for a Competitive Advantage

2 The direct impact of ICD code change on the application level may not be big but the ongoing implications of this change will be massive considering its indirect impact affecting complete Financials, Adjudication and Payments, Disease management, Benefit management and other applications & workflows. Therefore, ICD 10 related change should be considered more than just a tactical IT exercise. HCL Technologies fully integrated solution suite and transformation framework makes ICD 10 transition smooth and efficient today while helping you leverage its business impact for long term strategic advantage. icrf: An Integrated e2e ICD 10 Transformation Framework COE Business Intelligence & Data Warehouse Enterprise Transformation Services Infrastructure Mainframe Jave Microsoft Integration Domain Healthcare Payer SME Medical & Clinical BA & BPR Program Governance Knowledge Management People Training People Assessment Phase Policy & Process Changes Process Roll Out Phase Testing Phase HCL has multiple well tested frameworks, which have been utilized to create icrf these include PMSmart (for Program Governance), ArkMedes (for Knowledge Management), idpc (for Testing), Prizm (for Impact Assessment). icrf utilizes HCL s icrm (HCL s integrated Mapping, Modeling, Crosswalk) tool. icrf is supported by a detailed step-by-step workflow and a rich repository of templates, artifacts and best practices. icrf is enabled via automation and has multiple levels of in-built dashboards, trackers and status reports which are role and track based. icrf is supported by HCL Payer Academy to train and certify practitioners Testing Solution Phase Integration Business Integration Integration Crosswalk System Upgrade Remediation Approach Preparation Field Expansion Technology Impact Assessment Business Impact Assessment Production & Roll Out New System PM Smart arkmedes IDPC Framework exact Methodology Prizm icrm At the core of icrf is HCL s industry leading crosswalk, mapping & analytics tool icrm. icrm Technology

3 Developed by a team of physicians, clinicians, medical coders, technology experts & health insurance industry veterans HCL s icrm is an end to end ICD transformation tool & offers several differentiators like: Bilateral Mapping: HCL s bilateral mapping functionality includes mappings which were not covered by GEMs. These mappings are over and above GEMs and have been created both for forward and backward mapping. Historical Data Analysis: i-crm is designed to analyze and identify the ICD-9 codes that have one to- one, one-to-many and No match to the corresponding ICD-10 codes. This analysis would help determine the specificity of the mapping and the effect it will have on reimbursement. HCL Rules: HCL s five levels of rules edits for both forward and backward mapping will enable Payers to narrow down from multiple to minimum possible choices and ultimately choose a single code from ICD-10 (forward mapping) and ICD-9(backward mapping) without losing the clinical integrity of the claim. Crosswalk for Live claims: i-crm has the capability to convert incoming live claims (via the EDI gateway) incase the Payer plans to process all ICD-10 based claims with ICD-9 based adjudication systems. This feature will maximize the Auto Adjudication. Reimbursement Mapping: CMS created Reimbursement Mappings in an attempt to identify the best mapping option for reimbursement purposes. The reimbursement mappings focus only on backward mapping i.e. ICD-10 to ICD-9. I-CRM leverages these mappings to help payers do a 1:1 map in backward mapping. Financial Neutrality: DRG s play a vital role in determining pricing in a claim. i-crm helps determine which ICD codes have potential DRG shifts in the historic claims. Thus helps Payers do an analysis on how they can achieve financial neutrality. HCL s icrm provides features to analyze data, configure rules, and automate the mapping from ICD- 9 to ICD-10 codes. icrm will help Payers address all crosswalk requirements at an enterprise level. HCL also offers various services around the tool with technical and domain capabilities to expedite the process of implementing ICD-10 at an enterprise level. icrm is developed as a web based tool that can be integrated with any application or system in the Payer portfolio. It addresses all types of integration and data handling with respect to real-time, batch and user queries. HCL s Other Services for ICD 10 Transformation ICD Remediation Services HCL established its ICD-10 CoE in 2009 to assist Payer and Provider organizations in achieving a smooth transition to ICD-10. The ICD-10 CoE has a dedicated pool of roughly 500+ HCL resources made up of senior representatives with strong healthcare domain expertise, including practicing physicians, nurses, medical coders, clinical analysts, domain analysts, business consultants, solution architects, and technical experts The ICD-10 specialists from HCL help mitigate the risks posed by the complex coding change, align to the principles of Neutrality and ensure that benefits and member out of pocket payments are dealt with accurately with the highest level of automation through a tested approach: Business Remediation Services (Mapping Competency Center) To ensure successful remediation of business artifacts, HCL has established Mapping Competency Centre, a tested approach, which will serve as a translation backbone and help successfully remediate all the business artifacts (medical policies, provider contracts and benefits). Mapping Competency Centre helps to consolidate and prioritize business artifacts for remediation, do the mapping, conversion and outcome analysis for ICD codes and will perform multiple iterations (HCL prescribes 3 iterations), the outcome of which will recommend map revisions. For efficient execution of Mapping Competency Centre, HCL has set-up a well-defined Governance Framework, comprising standard operating process, decision/accountability frameworks and compliance monitoring mechanisms.

4 Technical Advisory Services HCL s technical advisory services helps healthcare organizations to plan the entire remediation cycle with minimal impact on day-to-day business operations. The execution approach will begin with Assessment and Planning Phase followed by a Proof of Concept for remediation. These are finally followed by review and finalization approach of overall remediation plan and a complete remediation phase. All of these phases are supported by various tools and accelerators designed specifically to assist in remediation process. ICD-10 Testing Services The change to the ICD-10 code sets will require updates to multiple systems and applications within a payer. Hence, testing will certainly need to include end-to-end, cross-functional, regression, internal and external components. ICD-10 would also require analytics for validating results of the test transactions, and impact to business process of those results. In particular, if crosswalks are involved, there will be a need to analyze the results in much greater detail. Testing will need to be well thought out and planned for in advance of the updates to reimbursement, utilization, underwriting and many other operational processes. In this scenario, planning a test strategy at the earliest opportunity, coordinating both internally and externally and leveraging efficient and comprehensive testing methodologies ensures a low-risk, high-quality output from testing. In addition, organizations should explore the many tools available to help with testing needs, which can ultimately reduce time and cost for these projects. HCL s idata Prepare idata Compare tool allows payer s to import a significant number of historical ICD-9 claims (e.g. two years) and convert them to ICD-10 claims (see diagram).

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6 HCL s recommends ICD-10 remediation testing as follows Payers should analyze their own historical data to understand the ICD-9 distributions with respect to ICD-9 codes usage per provider, contribution to pay out per ICD-9 code, distribution of codes in the 23% of ICD-9 codes mapping 1 to many ICD-10 codes, etc. Use the analysis reports to identify the right set of claims with high priority ICD-9 and 10 codes to test, since it would be difficult to test all codes Prepare the test environment for executing the tests on end-to-end processes Compare the outcomes of EOBs and ERAs to ensure that benefits and provider reimbursements are identical for the same claim with ICD-9 and equivalent ICD-10 codes HCL s unique approach and its toolsets are equipped with the intelligence to analyze historical data and be able to cull out a statistically valid dataset. This approach helps to test all applications in sequence to ensure that the maps developed with various factors like clinical equivalence and financial neutrality are intact. the WorLD the WorLD is NotiCiNg is NotiCiNg SOMETHING SOMETHING UNIqUE UNIqUE ABOUT ABOUT HCL HCL The World is Noticing Something Unique about HCL HCL s Employees First First is a is new a new and HCL s Employees First is a new and and radical management radical philosophy management which philosophy will which will catch on with which catch the world will on with catch sooner the on world with the sooner world or later sooner or later or later Harvard Business Harvard School Business teaches School teaches about HCL as about a case HCL study as on a case business study on on business transformation business transformation highlighting transformation the highlighting Employees high-lighting the Employees First initiative the First Employees initiativefirst initiative Best Employer Best in India Employer in India in India Hewitt Study Hewitt 2009 Study Study One of Britain s One Top of of Britain s Employers Top Top Employers for Employers the for for the 4 th Consecutive the 4 Year 4th Consecutive Year Employees Employees First, First, Customers First, Customers Second Customers Second is Second is now a book published is now a a book by published Harvard Press. by by Harvard Press. 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