The Clearinghouse and ICD-10

Transcription

1 The Clearinghouse and ICD-10 Pathway to Success by Tom Waller, Sr. Manager - Emdeon 1

2 Survey Question #1 I think ICD-10 will be: 1. Easy, I'm planning a vacation in October of next year 2. No different than 5010, some confusion and delayed revenue 3. The end of our business. I too am planning a vacation. 2

3 US Healthcare Milestones Transition to NPI Transition to ANSI v4010 Transition to ANSI v5010 ICD-10 - October 1, 2014 for most claims ICD-10 will be the first time that your clearinghouse cannot make the transaction work without significantly altering the clinical data ICD-10 has the potential to alter elements used to reimburse providers and the underlying analytics used to support reimbursement 3

4 Know Your EDI Format(s) In what format do you exchange data with your vendor or clearinghouse? ANSI v5010 o Great, this is the preferred interchange format UB04 o Can carry the data, check that the receiver will support Revised CMS1500 o Can carry the data, check that the receiver will support UB92, v4010, Original CMS1500, HCFA 1500 o None of these formats were designed to support ICD-10 4

5 Survey Question #2 I will have coded ICD-10 claims from my core system ready for EDI submission: 1. Ready now 2. Before the end of the year 3. First quarter Second quarter Third quarter

6 Know Your Payers and Your Reimbursement Structure Reimbursement impact is high on the list of CFO concerns. Have a list of payers and plans, knowing your financial risk. Do your payers talk about revenue neutrality? Are any portions of contracts diagnosis or DRG related? Are you in negotiations? Do you know the DRG specifics from the payer? Possible DRG shift is a top concern for institutional providers. 6

7 Discussion Points Between Provider and Payer If they are not v5010 capable today What is their remediation or contingency plan? Paper claims Compliance readiness Testing willingness Who, what, where, when and how 7

8 Know Your Partners and Systems Inventory your payers Inventory your connectivity pathways Initial Clearinghouse Are claims delivered to another clearinghouse before delivery to the payer? Don t forget about secondary claims Don t forget about secondary systems that consume claim data HIS/POMIS Can you control ICD-9/ICD-10 at the payer or plan level? Are you able to dual code natively? Is there a coding converter in place 8

9 Snapshot from the Clearinghouse Confident in our ability to move v5010 EDI Vendor partners and providers have exchanged EDI No Aha moments. EDI as usual No huge EDI changes are required We implement diagnosis code changes regularly 999 s, 277 s and 835 s We are a year away, and it feels like it Limited number of providers have natively coded ICD-10 EDI available for testing today Limited provider data means limited ability for payers to test with live data Payers who are not v5010 ready Providers who not v5010 ready 9

10 Why Test with Your Clearinghouse? Demonstrate your ability to create properly formatted ICD-10 claims Determine if your ICD-10 files will pass clearinghouse editing. May facilitate payer testing 10

11 Things to Ask Your Clearinghouse Are you ready to test? If not now, when Costs associated with testing? Limitations as to time or quantity? What will the clearinghouse return? How do you facilitate payer testing? 11

12 Survey Question #3 I am confident that my payers will test with me: 1. Strongly agree 2. Moderately agree 3. Disagree 4. Strongly disagree 12

13 Why Test With Payers? ICD-10 testing is much different that v5010 testing Many more scenarios than v5010 May want to test high volumes of claims Most testing is multi-round Testing is focused on clinical content and not EDI Quantify payer readiness Ensure that EDI works Identify variances in provider/payer handling Reimbursement variance Denial handling 13

14 Benefits of Testing for Payers Early natively coded claims pointed to some wide variations of code use Payers become more familiar with how providers interpret and use ICD-10 codes Have a source of live data to test claims processing and adjudication Better understand industry readiness 14

15 Testing Sounds Like a Good Idea When Can I Start? Determine what payers will test with you Not all will be willing Review your pathway to reach the payers Are all partners ready to test? Look for strategies what allow parts to function independently Determine test criteria Some payers have membership, service date or specific historical claims they want to test What will the outcome of the testing be? Not all payers will be able to reply with a standard 835 file Assess your ability to read and review any response data 15

16 What Have We Seen in Provider Testing? Mixing ICD-9 and ICD-10 codes on the same claim Failing to correctly indicate the coding method Not updating the Procedure codes 16

17 What Have We Seen in Payer Testing? Easy transition of EDI Early issues with crosswalks Confusion over codes being used as compared to ICD-9 Reimbursement calculation snafu s 17

18 Questions? 18