Transformation through ICD-10 Adoption

Transcription

1 Transformation through ICD-10 Adoption The ICD-10 mandate presents payers and providers with one of the largest, most complex, regulatory challenges to date. Migration to the ICD-10 coding scheme is a mission-critical project and must be well-planned. Syntel s unique nsure10 SM offering is well-equipped to help you develop a roadmap and navigate your team to compliance and beyond. Our phased approach to adoption will build on basic compliance to elevate your investment and transform your organization. Syntel s nsure10 SM approach delivers compliance and TRANSFORMATION. Syntel nsure10 SM > Modernization and system improvements > Tool driven assessment leading to up to 50% effort savings > Business consulting for process reengineering. > Advanced testing tool suites. > Commitment beyond compliance through BI/Analytics. > Customizable solution to suit the needs and strategies of individual organizations The Syntel Advantage > Domain depth and hands-on experience Sustenance Basic Compliance Basic Compliance with minimal changes Implement Translation Logic Cost Effective Expansion Process Optimization Process and Performance Optimization Modification of primary impacted systems Moderate Investment Transformation An Opportunity New, Innovative Business Models Leverage Healthcare Domain Capabilities (P4P, Fraud, Revenue Cycle, Patient Care ) Reap of ICD-10 Investments > Healthcare focused R&D teams > TriZetto and MetaVance competency centers > End-to-end revenue cycle management test automation platform. > Dedicated healthcare innovation lab > Integrated ITO/KPO solutions

2 Long term, ICD-10 adoption can become the basis for greater analysis of health information, yielding better medical data, as well as improved predictive modeling and care management. Gartner, Hype Cycle for Healthcare Payers, 2008 ICD-10 migration is a strategic initiative and involves quantum changes which require both effort and capital. Understanding the challenges faced by healthcare organizations, nsure10 SM recommends and provides flexible solutions that support the various approaches organizations take in implementing these significant changes. Sustenance Basic Compliance with Syntel s nsure10 SM Translator The initial goal of migration will be to address the regulatory requirements. Basic compliance is vital to take advantage of the rich data captured. To ensure this, health plans will need to add the ability to communicate with trading partners and perform basic claims adjudication. Similarly, providers will need to modify their clinical and revenue cycle management system to be able to do produce bills with appropriate ICD codes for patient care reimbursement. This will involve modification of the major impacted applications to accommodate required changes and building a suitable crosswalk for translating codes. An approach that focuses on minimizing costs is Syntel s nsure10 SM Translator that intelligently translates codes from ICD-9 to ICD-10 and ICD-10 to ICD-9 using standardized mapping logic such as the General Equivalence Mapping (GEM) and Reimbursement Mapping published by CMS. Being platform independent and centrally located, our Translator acts as a bridge across multiple systems and supports coordination of changes. This is a valuable strategy to meet the needs of the changing healthcare regulations without significant modification to existing systems. For some organizations, a parallel-run stage where both ICD-9 and ICD-10 compatible systems are used may be required. Expansion Process Optimization Increasing ICD-10 Utilization Organizations can elect to leverage the new codes with increased utilization for improving operations of key processes. This approach involves implementing ICD-10 in business areas that are critical to an organization s functioning and necessitate immediate attention. Provider systems such as Medical Coding, Revenue Cycle will have to be enhanced to exploit the benefits of ICD-10 upgrade and expect a faster and cleaner claims processing. Likewise Payer modifications in areas such as Product Build, Enrollment and Fraud will ensure quality inputs for claims processing and deliver quicker and more accurate claims adjudication. Transformation Turning ICD-10 Compliance into an Opportunity ICD-10 provides an opportunity to create innovative business models. With the data collected, organizations can perform detailed and rich analysis in areas such as care management, disease management and underwriting. Similarly, providers can make the most of the granularity in ICD-10 by performing healthcare intelligence analytics in patient safety and care management, denial management, A/R tracking.the granular details in ICD-10 collected over a period of time will drive improvements in patient safety and care. Syntel nsure10 SM provides an end-to-end offering that can be blended and customized to meet the purpose of every organization s adopted strategy. Designed meticulously to meet the changing business needs, Syntel s nsure10 SM components, methodology and services guarantee a linchpin solution to all concerns and provide benefits that are far reaching.

3 Business Impact System Impact Gap Analysis Size Reports Minimal SME intervention Upfront Obsolete /Redundant Code Identification Reduced cost and manual efforts Blue Print Business & Technical Implementation Plan Migration Effort Estimation Pilot Project Planning Training Communicates complex information quickly Provides simple version of business issues for faster understanding and action Presents consolidated view of business area impacts Implementation Design Implement Blueprint Application Integration Unit Testing Configurable and customizable mappings through ICD Translator tool Data conversion strategy to handle Historical Data Zero interruption to the ongoing enterprise activities Testing Test Strategy Planning Test Data Test Region Set up Test Case System/Integration & Regression Testing Trading Partner Testing Achieve higher state of business readiness for ICD-10 Increased ROI by optimizing cost Accelerate time to market and increase productivity Processes Impacted Most of the health plan s and provider s processes are affected by the ICD-10 adoption. Technology applications as well as business processes will have to be modified to accept and utilize the ICD-10 codes. All outputs obtained (such as reports) will also need modifications to incorporate the ICD-10 codes. There will be a significant impact to the business rules within applications as well. The greatest impact will be on the following processes: > Product Development > Enrollment > Billing and Blueprint Before embarking on the overall migration, it is important to evaluate the impact of ICD-10 on the organization s applications, organization structure and training needs. With a toolbased approach, the assessment will estimate the efforts required and prepare inputs required for the blueprint.. The assessment will help plan budgets, resources and even formulate strategies for the implementation. Based on the findings, it may be important to create a program office and a budget to run this program as a corporate initiative in a structured and systematic manner with participation from different sub-units including IT and business. The next step is to prepare a blueprint to define the overall program. Healthcare organizations must also evaluate IT vendor capabilities for a structured approach towards implementation. Organizations without vendor outsourcing relationships must give serious thought to identifying a partner to work with through the completion of ICD-10 adoption. The following step is to prepare the project blueprint, a comprehensive phase-wise plan for implementation with detailed timelines and deliverables. The blueprint takes into account any release plans or scheduled business or system changes planned to impacted systems during the ICD migration timeline. Typically, the blueprint will include a pilot implementation to validate the approach and make adjustments to the plan, especially since this migration explores unchartered territories. It will help the organization cross the bridge between understanding the impact and implementation of the vast migration process. > Claims Processing & Adjudication > Care and Disease > Internal Fraud & Audit Research and Analytics > Medical Coding > Contract > Patient Care

4 Gartner believes that the effect of ICD-10 on health insurers will be greater than that of HIPAA and Y2K combined. Gartner, Hype Cycle for Healthcare Payers, 2008 Implementation and Testing Implementation involves the action oriented steps carried out post assessment and blueprint phase to get applications and systems compliant to handle the new code systems. This phase entails the implementation of the project blueprint which includes requirement gathering and designing of the new system. Following this, the actual coding and execution takes place at the system and application level which allows conformance by bridging the gaps that exist between the standard practices followed and the new mandates. The next step includes testing of the remediated systems so that all the internal systems and external trading partners are proactively aligned and ready to accept the new codes and formats. The testing approach includes discovery, design, execution and reporting, supported by tools/accelerators that facilitate rapid validation and test data generation. This approach allows all the internal systems to be fully equipped and tested with no untouched and unattended gaps. Testing activities focus on test case management, defect management; customized test repository to suit payer and provider businesses ensuring highest quality of the test data for successful testing and foolproof system Beyond Compliance Syntel s Healthcare Business Intelligence and Analytics solutions help organization s think strategically, foresee upcoming trends, and develop plans to ride the trends. Payers can safeguard against fraud management through our BI/Analytics solutions. Similarly providers can analyze their patient satisfaction score card after an improved patient care with ICD-10 adoption and research. Syntel nsure10 SM Framework Syntel nsure10 SM offering is built on a scalable model with cross functional application to payer, provider and clearinghouses. Integrating Process, People and Technology, it presents a solution that is cost effective, technologically advance and resource efficient. The nsure10 SM toolkit has tools that span assessment through testing phases and allows deft traversal from ICD-9 based code system to ICD-10 based code system. In addition, Syntel provides proprietary and exclusive solutions for testing and Healthcare business intelligence and analytics to drive value from your ICD investments. TOOLS Impact Analyzer: Facilitates source code impact Analysis Auto Code Changer: Utility with rules set to change the field length and make multiple code changes automatically Translator: Analysis of complexity of currently used ICD-9 and customizes ICD-10 mapping based on industry standard Step Up/Step Down Converter: Converts 4010 EDI transaction to 5010 in configurable manner EDI Testing Suite: 5010 Test Data RTF: Regulatory Testing Framework based on Syntel's ITAP PEOPLE Support Group Architect Group R & D Group Technology CoE Domain SME's QA Group nsure10 SM FRAMEWORK PROCESS FTE's Invested to develop a suite of tools Processes, templates, methodologies Experienced Resource Pool SWAT team for rapid deployment Knowledge Portal Testing Business Process SME's Beyond Compliance BTS Analytics Fraud and Abuse Care M & A

5 The Syntel Advantage > Domain depth and hands-on experience > Healthcare focused R&D teams > TriZetto and MetaVance competency centers > End-to-end revenue cycle management test automation platform. Implementation Challenges Understanding the challenges of ICD-10 adoption is critical to a successful migration. Some of the major challenges include: Migrating to X12 v 5010: As the first step to adopting ICD-10, with more than 850 individual changes, implementing 5010 is enormous challenge. Impact Analysis: A thorough assessment of the usage of ICD-9 codes to the business processes and components that are directly or indirectly impacted is required. Modifications to Business Rules: ICD- 10 brings significant logic changes to applications that use these codes. For example, in claims adjudication, the edits to ensure proper payment or nonpayment for services will need to be revised. ICD-9 to 10 mapping: There is no direct one-to-one mapping available currently. The varied architectures and technologies further complicate the crosswalk activities. For example, the General Equivalence Mapping provided by CMS cannot be used in a legacy system in unaltered form. Transition: During the code transition phase, it is likely that applications will need the capability to handle the two coding systems concurrently. With the inconsistent relationship between the two coding systems, implementing a suitable crosswalk and maintaining dual coding structures will be a daunting challenge. Testing: The numerous variations in the ICD-10 codes require extensive internal and external testing. Internal testing involves testing of applications that use ICD-10 codes. External testing involves ensuring interoperability amongst trading partners. Trading partners will need to test using the new codes well in advance of the actual cutoff date. Staff training: Lack of a relationship between ICD-9 & ICD-10 poses a challenge for aging staff to get reoriented. Incomplete understanding of the new coding system will lead to decreased operational efficiency and improper reimbursements. Customer Service: Customer service representatives will be required to be prepared with phone scripts as there will be a rise in the volume of calls and inquiries. > Dedicated healthcare innovation lab > Integrated ITO/KPO solutions