IQ ICD-10 EMR Based Predictive Modeling and Dual Coded Solutions

Transcription

1 IQ ICD-10 EMR Based Predictive Modeling and Dual Coded Solutions Discussion with AHIP ICD-10 Task Force August 18, 2011

2 AGENDA Corporate Introductions Understanding the Industry Needs for Test Data, Testing and Modeling Objectives for Today s Meeting Overview of our Unique Approach to ICD-10 Next Steps 2

3 CORPORATE INTRODUCTIONS INSIGMA A global IT and BPO service provider with a proven track record as a great partner for organizations looking to innovate and transform their business. Known for creative thinking and innovation around complex IT and business issues along with business-transformation capabilities, and change management expertise. A professional healthcare IT quality assurance and software testing firm delivering managed testing services with a strong foundation and expertise in all aspects of healthcare IT and software testing best practices. QUALEDIX THE PARTNERSHIP Together we bring comprehensive testing solutions, business process expertise and qualified/knowledgeable resources to help our clients meet their ANSI 5010 and ICD10 analysis and testing needs in a timely and cost effective manner. 3

4 Addressing Key Business Issues Understanding the Industry needs for test data, Testing and modeling Internal and trading partner testing Financial modeling, actuarial analysis & medical cost impact System configuration & automation accuracy Medical policies & product remediation Provider and network contract remediation ICD-10 compliance and business optimization 4

5 Objectives for Today s Meeting Introduce Our IQ ICD-10 Managed Services Show How Our IQ Managed Services & Unique Approach Meet the Industry Needs Better, Faster, Cheaper and More Accurately 5

6 Our Unique Approach IQ ICD-10 MANAGED SERVICES SOLUTION We provide a suite of managed services that delivers on-demand, cloud based, solutions to help plan, test and optimize your ICD-10 implementation. We help you leverage your ICD-10 migration to enhance patient care and business performance. Our suite of managed services includes: 5010 & ICD-10 internal and trading partner testing Authentic ICD-10 test data Coding and coding expertise Predictive modeling Financial impact analysis Policies, product and contract remediation 6 6

7 Our Suite of Managed Services IQ ICD-10 MANAGED SERVICES SOLUTION PROVIDES BOTH DATA AND BUSINESS TESTING VIABILEDI our 5010 testing data and services ensures your software readiness. VISIBILEDI this managed service delivers integrated trading partner testing across formats. AUTHENTICD the healthcare industry s only natively coded ICD-10 clinical based test data WHO WE ARE: A MANAGED SERVICE SUBSCRIPTION MODEL CLINICAL RECORD BASED 7 WHO WE ARE NOT: A TOOLS COMPANY CROSS WALKS BASED HARDWARE or SOFTWARE PREDICTABILEDI provides predictive analytics and data for healthcare business modeling & management COMPLEXEDI Data driven testing service for analyzing business rules & configuration logic INTEROPERABILEDI Alignment testing for 5010 and ICD-10 interpretation and compliance ADAPTABILEDI - ICD-10 coding, training and education managed services along with CBT Testing

8 Our IQ Managed Services solution uses clinical records and clinical scenarios to test and optimize business performance for icd-10. this is why we are unique and help our clients meet their Business needs.. better, faster, cheaper and more accurately Authenticd predictabiledi AUTHENTICD the healthcare industry s only natively coded ICD-10 test data 8 PREDICTABILEDI provides predictive analytics and data for healthcare business modeling & management

9 IQ AUTHENTICD Process 20MM+ REAL CLINICAL DATA SETS (EMR) FREQUENCY DISTRIBUTION FOR MODELING DUAL ICD-9 & ICD-10 CODING AUTHENTICD TEST BED 9

10 IQ MODELING DATA REPOSITORY PREDICTIVE MODELING DATA WAREHOUSE CUSTOMIZED FREQUENCY DISTRIBUTION PROVIDERS CLEARING PAYERS VENDORS 10

11 Iq ICD-10 SPECIFIC TEST DATA REPOSITORY DUAL CODED DATA WAREHOUSE HIPAA-HCFA-UB-ADA-NSF-FLAT PROVIDERS CLEARING PAYERS VENDORS 11

12 PREDICTABILEDI PREDICTIVE MODELING AND FINANCIAL IMPACT ANALYSIS PREDICTABILEDI Is an accurate historical record as if the industry coded in ICD-10 for last five years Informs the distribution of clinical events and the related reimbursement in ICD-10 Provides key indicators for identifying coding anomalies as they occur Defines the impacts to procedures and DRG s in ICD-9/10 Provides test case coverage for the things that matter Gives real time metrics for accuracy rates of newly coded transactions 12

13 Clinical Scenarios Matter Clinical Scenarios are the only way to test ICD-10 Scenarios developed from actual clinical records are natively coded in ICD-9 and ICD-10 Gold Standard for providers and payers today and the source of truth 13 Initial ICD-10 coding from providers will be inconsistent Initial accuracy rate 65% - 75% ICD-10 analytics also inaccurate Crosswalks like GEMS fail to provide specific answers that test configuration & rules

14 Clinical Scenarios Matter Getting It Done on Time: Picking the Right Scenarios It will be impossible to identify every process and potential area of risk, but we can greatly minimize risk by picking the scenarios that represent: High Volume High Cost/Revenue High complexity, or likely points of failure Anticipated opportunities of improvement of existing processes 14 Known to be problematic today (under/over reimbursed)

15 Beginning with a Known Event September 2013 October 2013 ICD-9 ICD : Open fracture of Shaft of Femur All codes for femur fractures = 16 S72351C: Displaced comminuted fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC All codes for femur fractures = 1530

16 TESTING THE NEW 10 WORLD AUTHENTICD CLINICAL SCENARIO CLINICAL PROCEDURE 56 year old male in the emergency room with acute onset of chest pain. An electro cardiogram shows ST elevation consistent with an anterior wall Myocardial Infarction The patient has subsequent enzyme elevations that confirm a myocardial infarction; the angiogram demonstrates an obstruction of the left main coronary artery Percutaneous coronary angiogram through the right femoral artery CLINICAL PROCEDURE Coronary artery bypass from internal mammary artery to the left main coronary artery What are the right codes in ICD-10? How accurate are crosswalk tools? How can I model what ICD-10 might look like? What is the current frequency distribution of these events? 16

17 TESTING THE NEW 10 WORLD AUTHENTICD Breakdown Bypass Analysis ~$65, Coronary bypass of one coronary artery ~$75, Coronary bypass of two coronary arteries ~$85, Coronary bypass of three coronary arteries ~$100, Coronary bypass of four or more coronary arteries 17

18 TESTING THE NEW 10 WORLD AUTHENTICD CLINICAL SCENARIO CLINICAL PROCEDURE 56 year old male in the emergency room with acute onset of chest pain. An electro cardiogram shows ST elevation consistent with an anterior wall Myocardial Infarction The patient has subsequent enzyme elevations that confirm a myocardial infarction; the angiogram demonstrates an obstruction of the left main coronary artery Percutaneous coronary angiogram through the right femoral artery CLINICAL PROCEDURE Coronary artery bypass from internal mammary artery to the left main coronary artery CROSSWALK APPROACH ICD-9 Codes all crosswalk to the same ICD- 10 Code I Coronary bypass of one coronary artery crosswalks to 02100Z3 Generic Bypass NATIVE CODING APPROACH Real CM Code is I ST elevation myocardial infarction involving left main coronary artery 02100A9 - Bypass Coronary Artery, One Site to Left Internal Mammary with Autologous Arterial Tissue 5% Radial Artery 25% Saphenous Vein 70% Internal Mammary 18

19 TESTING THE NEW 10 WORLD AUTHENTICD ICD-10 CM I ST elevation myocardial infarction involving left main coronary artery I ST elevation myocardial infarction involving left anterior descending coronary artery I ST elevation myocardial infarction involving other coronary artery of anterior wall I ST elevation myocardial infarction involving right coronary artery I ST elevation myocardial infarction involving other coronary artery of inferior wall I ST elevation myocardial infarction involving left circumflex coronary artery I ST elevation myocardial infarction involving other sites I213 - ST elevation myocardial infarction of unspecified site 19 ICD-10-PCS 02100A3 - Bypass Coronary Artery, One Site to Coronary Artery with Autologous Arterial Tissue 02100J3 - Bypass Coronary Artery, One Site to Coronary Artery with Synthetic Substitute 02100K3 - Bypass Coronary Artery, One Site to Coronary Artery with Nonautologous Tissue Substitute Bypass Coronary Artery, One Site to Right Internal Mammary with Autologous Venous Tissue Bypass Coronary Artery, One Site to Left Internal Mammary with Autologous Venous Tissue 02100A8 - Bypass Coronary Artery, One Site to Right Internal Mammary with Autologous Arterial Tissue 02100A9 - Bypass Coronary Artery, One Site to Left Internal Mammary with Autologous Arterial Tissue 02100J8 - Bypass Coronary Artery, One Site to Right Internal Mammary with Synthetic Substitute 02100J9 - Bypass Coronary Artery, One Site to Left Internal Mammary with Synthetic Substitute 02100K8 - Bypass Coronary Artery, One Site to Right Internal Mammary with Nonautologous Tissue 02100K9 - Bypass Coronary Artery, One Site to Left Internal Mammary with Nonautologous Tissue

20 Focus on Higher Costs Analysis of 3 years of inpatient payer data for ~ 1million lives: Only 28% of the 14,432 possible ICD-9 diagnosis codes were used 3% of the possible codes accounted for 80% of billed charges Top 5 charge categories*: 17.5% = Diseases of the circulatory system 13.8% = Diseases of the musculoskeletal system and connective tissue 9.7% = Injury and poisoning 8.9% = Diseases of the Digestive System 8.8% = Neoplasms * AHRQ Clinical Classification System level 1 categories (based on primary diagnosis) 20

21 Focus on Higher Costs Analysis of 3 years of inpatient payer data for ~ 1million lives: Only 43% of the 3,859 possible ICD-9 procedure codes were ever used 8% of the possible codes accounted for 89% of billed charges Top 5 charge categories*: 21.7% = Operations on the cardiovascular system 19.5% = Operations on the musculoskeletal system 14.4% = Operations on the digestive system 13.1% = Miscellaneous diagnostic and therapeutic procedures 9.1% = Obstetrical procedures * AHRQ Clinical Classification System level 1 categories (based on primary ICD-9 Procedure) 21

22 Focus on Higher Costs Top 5 MDCs*: 17.3% = Diseases& disorders of the musculoskeletal systems & connective tissue 16.6% = Diseases and disorders of the circulatory systems 8.7% = Diseases and disorders of the digestive system 8.5% = Pregnancy, Child birth & The Puerperium 7.1% = Newborns and other neonates with conditions originating in the perinatal period * MSDRG classification 22

23 Focus On Higher complexity 1.4% (diagnosis); 7.6% (procedure) of billed charges are related to combination codes (requiring more than one ICD-10 code). 23% (diagnosis); 85.3% (procedure) of billed charges are related to ICD-9 codes that have more than one GEM ICD-10 code choice Codes related to acute myocardial infarction, pregnancy, diabetes and other common conditions have changed definitions and rules for coding A number of procedures will have very different definitions in ICD-10 23

24 Focus on Higher complexity Codes impact other functions that don t directly relate to billing and may have a significant impact on other business areas such as: Quality measures Severity adjustments Hospital acquired conditions Fraud, waste and abuse detection Contracting scope Capitation and carve-outs 24

25 Delivery Models Matter DELIVERY MODELS MATTER Brick & Mortar Next Generation VS Silo Delivery Approach Shared Delivery Approach 25

26 Delivery Models Matter DELIVERY MODELS MATTER Silo Solution (brick/mortar/internal) Enormous initial expense Heavily resource dependent requiring internal expertise Data only valid internally Throughput issues with users waiting in long lines License fees based on users Long initial delays for ramp up No ICD-10 test data to copy One vendor s view of compliance Always an internal cost center Shared Solution (next generation/national test bed) Low upfront costs Highly targeted resources provided with expertise Data valid across trading partners Multi-threaded delivery for quick response times No user based license fees Ready immediately Natively coded ICD-10 test data Industry view of compliance Easily pays for itself in first year 26

27 Delivery Models Matter IQ DELIVERY MODEL VALUE NO CENTRAL REPOSITORY CENTRAL REPOSITORY Test Data Tool License Trading Partner License Test Data Tool License Trading Partner License Crosswalk Tool License Test Data Resource Cost Crosswalk Tool License Test Data Resource Cost Inaccurate Data Costs Accurate Data Savings NO TRADING PARTNER COORDINATION SHARED DATA WITH ALL TRADING PARTNERS High Risk and High Cost Low Risk and Low Cost 27

28 Industry COLLABORATIVE MODELING PREDICTIVE MODELING DATA WAREHOUSE CUSTOMIZED FREQUENCY DISTRIBUTION PROVIDERS CLEARING PAYERS VENDORS 28

29 industry COLLABORATIVE DATA REPOSITORY DUAL CODED DATA WAREHOUSE HIPAA-HCFA-UB-ADA-NSF-FLAT PROVIDERS CLEARING PAYERS VENDORS 29

30 industry NATIONAL TEST DATA REPOSITORY PAYER 1 CLOUD PAYER 2 CLOUD PAYER 3 CLOUD PAYER 4 CLOUD PAYER 5 CLOUD VIABILEDI - WEB SERVICE LAYER PHI CUSTOMIZATION / 256 BIT ENCRYPTION THROUGHPUT = 10,000 TRANSACTIONS PER HOUR PAYER 1 LOCAL PAYER 2 LOCAL PAYER 3 LOCAL PAYER 4 LOCAL PAYER 5 LOCAL 30

31 VALUE PROPOSITION IQ PREDICTIVE MODELING AND TEST DATA GENERATION BENEFITS Others IQ 31 Sells Tools Based on Crosswalks Removes User Licenses from Testing Cost Increases Efficiency and Accuracy of Test Data Test Data is Peer Reviewed Through Utilization by The Industry Test Data is Usable by Your Trading Partners Test Data Any Format UB/HCFA/4010/5010 Test Data Quality Contractually Guaranteed Managed Service Eliminates Capital Expenditures for Testing Reduces Operations Expenses for Trading Partner Testing and Outreach State of the Art Robust Technology Via Cloud Computing Hyper Specialized Services Designed for End to End Testing Highly Scalable Delivery Solutions Through Capacity on Demand Model High Volume Diverse EMR Database for Clinical Records Analysis Predictive Modeling Based on Native Provider Data Not ICD 9 Codes ICD 10 Expertise in Diagnosis, Coding and Testing High Acumen in Software Testing and Healthcare Expertise National Test Data Repository for Healthcare End to End Testing Methodology for ICD 10 Implementation Monthly Test Data Updates on X12 Interpretation Changes

32 VALUE PROPOSITION We provide the ability to predict business impact and effectiveness of remediation anchored in historical models of what the industry knows to be true today Clinical Scenario Based Testing Predictive Analysis of Business Impacts Shared Service Delivery Model Greatly Lowering Cost Frequency Distribution & Business Modeling to Address Business Risk Only Viable Method Available in the Industry Today for Creating Accurate Clinically Based Test Cases 32

33 For Additional Information Please Contact: Veronica Dunleavy Mark Lott