Coventry Health Care. ICD-10 Program Overview Provider Collaboration, Financial & Benefit Neutrality Testing and Business Readiness

Transcription

1 Coventry Health Care ICD-10 Program Overview Provider Collaboration, Financial & Benefit Neutrality Testing and Business Readiness Copyright 2015 Coventry Health Care, Inc. All rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronically or mechanical, including photocopy and recording, for any purpose without written permission of Coventry Health Care, Inc. Version of Methodology R2012

2 Contents ICD-10 Program Overview Provider Collaboration Testing Approach Results Lessons Learned Financial and Benefit Neutrality Approach Results Lessons Learned Metrics Monitoring for Business Readiness Collaboration with Aetna Metric Definitions 2

3 ICD-10 Program Overview Coventry s transition to the ICD-10 code set included: Corporate PMO Project for ICD-10 compliance was initiated in We began the project by completing all analyses, including gap and system impact inventory, and system remediation. We engaged the impacted areas of our company in our business assessments to understand the impacts of processes and policies due to moving to the new coding system. Our project was defined in 7 phases, each with work packages linked to applications and teams. o Each Work Package contained Design, Construction, Testing and Deployment Life Cycle deliverables for each sub-project team. Part of our project included collaboration testing with our vendors and other trading partners to ensure compliance with the ICD-10 code set. 3

4 ICD-10 Program Overview We began Provider Collaboration testing in 2012 and completed in o Coventry was identified as an Industry Leader for our end to end test accomplishments at the WEDI 2012 Fall Conference. Financial and Benefit Neutrality testing took place from June 2013 April o Our stated goal was to understand the shift in reimbursement and any impact on member benefits and benefit rules. We continue to monitor CMS for any industry updates concerning the transition from ICD-9 to ICD-10. We plan to be fully ready to process ICD-10 claims on October 1, Coventry began ICD-10 project in Systems are updated and are ICD-10 ready. Reviewing business readiness. On track for October 1, 2015 compliance. 4

5 Provider Collaboration Testing 5

6 Provider Collaboration Approach Provider chose one of the methods of testing shown below. Provider was sent a use-case scenario document to complete and return. A conference call was scheduled with Coventry, the provider and Emdeon (claims clearinghouse) to review and discuss the testing process. Providers chose previously-submitted Coventry claims, re-coded the claims using ICD-10 codes, and submitted the claims for testing to Emdeon. If choosing an EDI Method, claims were submitted and adjudicated at Coventry. Providers received a spreadsheet with all the results found on the standard 835 electronic claim transaction. If the provider chose a paper claim or an alternate testing method, re-coded claims were sent securely to Coventry and processed. The provider received a spreadsheet with all results. Example, full End to End EDI with channel partner Example full End to End EDI Example of Paper/Alternative Testing Provider Provider Coventry Channel Partner Provider Coventry Emdeon Coventry Emdeon

7 Provider Collaboration Results Coventry scheduled 20 windows of provider collaboration testing. Testing was open to any provider who submits member claims to Coventry. Both professional and institutional claims were allowed and the provider chose the claims they wanted to test. Over 1500 claims were submitted by 21 providers. All of our system platforms were tested in the process. Our test environments mirrored our live production environments. If claims pended with ICD-9 codes, they also pended with ICD-10 codes. We applied the test claims to all of our rules banks as if the test claims were live claims. We had claims processors available to work any pended claims. Our goal was to provide as much information as possible to the provider. Findings Over the course of testing we observed only minimal issues. We observed 4 DRG shifts, all of which were due to the secondary diagnosis. For example, we observed DRG 693 shift to DRG 694. We also observed some header codes submitted; these are not valid payment codes and were rejected. We observed a few rejections at the clearinghouse level as well as the Coventry level. The Coventry rejections were due to member-not-found or invalid date scenarios. Emdeon s rejections included invalid procedure codes, invalid diagnosis codes, and missing information on the attending physician. 7

8 Provider Collaboration Lessons Learned Title Coventry Test Environment Readiness Lesson Learned / Defects Corrected Coventry discovered that some environment-preparation steps necessary to turn on/off objects that are needed for successful testing were missing. These errors were found during the processing of a provider s test claims and delayed the turnaround time to send the processed claims back to Emdeon; this was due to the manual re-work and re-adjudication of the claims. Testing Coordination with other project testing Some testing required coordination with other active project teams (for example, ihealth file testing). Coordination was proactive and both testing cycles were subsequently completed without delay. Timely Filing Timely filing rules state that claims must be filed within a specific number of days after the date the service. The timely filing window may vary from provider to provider; some may be 90 days, others 180 days, etc. To determine if the timely filing rule was met on a claim, Coventry systems compared the date of receipt, date of service, and the appropriate timely filing rule. During Provider Collaboration testing, to successfully process test claims it became necessary for providers to select test claims that fell within the appropriate window. Submitter for Multiple providers Coventry and Emdeon require single providers for each test file and not multiple testers in a file. This is due to the test claims going through the test environments which can't have multiple TINS in the 837. High-level vs. specific codes When a claim is processed through Emdeon s system, if the DX code is on the ICD-10 code table (no matter the level) the claim is accepted. For Coventry claims, Emdeon edits to validate ICD-10 specificity are not enabled. As a result, many claims were denied due to a lack of specific codes, and those test claims needed to be re-submitted in order to be successfully processed. 8

9 Financial and Benefit Neutrality Testing 9

10 Financial & Benefit Neutrality Approach GOALS Determine the level of variance on financial and benefit neutrality due to the transition from ICD-9 to ICD-10. Conduct a financial (contract allowed and paid amount) and benefit (deductible, coinsurance, copay) risk analysis to understand the shift in reimbursement and any impact on member benefits and benefit rules. Validate the adjudication processes within Coventry internal systems. Identify scenarios where ICD-9 to ICD-10 mapping causes variances and communicate to impacted Business area for remediation. Where appropriate, Provider Networks Team to evaluate contract updates to the providers for feedback and agreement. 10

11 Financial & Benefit Neutrality Approach Objectives Execute 6-12 testing cycles over 12 months by conducting parallel and regression testing for Financial and Benefit risk analysis from ICD-9 to ICD-10 codes for IDX and MCPS claims. Test approximately 5 million total claims in the ICD-9 Test environment and in the ICD- 10 test environment. Understand the shift in reimbursement and any impact on member benefits and benefit rules. Where appropriate, the Business remediates their systems to an agreed-upon level of variance. 11

12 Financial & Benefit Neutrality Results Processing Accomplishments Performed 6 Cycles of testing + one smoke test from June 2013 April million claims filed for both ICD-9 and ICD-10 transactions with 99.96% overall neutrality. Included Institutional, Professional, and Dental Claims processed on IDX and MCPS. All active HMO s as of 05/27/2013 included in test. 12

13 Financial & Benefit Neutrality Lessons Learned Lessons Learned: Timing of claim adjudication on 10.2 million claims on the different IDX platforms often impacted outcome and required review of claims when no real issue existed. The coordinated effort of all cross-functional participants was essential for successful remediation. 13

14 Metrics Monitoring 14

15 Metrics Monitoring for Business Readiness The ICD-10 code change has the potential for a much broader impact than just on claims and payments. The entire medical delivery system, policies, methods, and trending could be affected, which could then have a downstream effect on other business drivers. Aetna worked with their business areas and determined what metrics would be the most impactful for ICD-10. They have shared these metrics with Coventry for our consideration to track the same or similar. Aetna s set of 14 metrics were derived from Claims Operations, Medical Management, Provider Network Contracting, Medical Economics, and Service Operations. 15

16 Metrics Monitoring for Business Readiness Thresholds were determined and established based on the baseline information. Coventry will measure 13 of the key Aetna metrics and will baseline the information by collecting statistics back to October 1, Metric data will be captured by: o o o Coventry Total By Product Line (Commercial, Medicare, Medicaid, FEHP) By Health Plan With the framework in place, an executive dashboard or report was developed to capture a quick snapshot of the results individually for both Coventry and Aetna. 16

17 Metrics Definition Metric Title Metric Definition and Variable Consideration 1. EDI Claim Intake Volume Total number of claims received at the Aetna EDI Gateway 2. External Clearinghouse Claim Reject Rate Total number of claims rejected, at the clearinghouse vendors Sum of Total number of claims rejected and accepted at the clearinghouse vendors 3. ACS Imaged Paper Claim Intake Rate Total number of claims submitted via traditional data capture total claims received 4. IDX Claim Intake Rate Total number of claims submitted via paper data capture (True Paper) total claims received 5. Manual Claims Intake Volume Total number of claims submitted via paper data capture (True Paper) total claims received. 6. Auto Adjudication Rate Total number of claims Auto Adjudicated on the first attempt the total claims resolved 7. Percent of Claims Paid w/in 15 days & 30 days 8. Day of Service to Date Received Turn Around Time % of claims paid from date received to 15 days and % of claims paid from date received to 30 days. Total number of days [from day of service] it took for claims [received that week] to be received 9. Claim Denial Rate Total number of claims rejected total number of claim transactions. 10. Volume of Documented Provider Issues Quantity of issues logged based upon interactions by EDI consultants and/or provider service center representatives. 11. Volume of Members Identified Total number of members identified for Case management and Disease management programs. 12. Average Amount Allowed per Admit (Commercial & Medicare) Total dollar amount allowed for all admits total number of admits 13. Case Mix Index (CMI) Total DRG weight total number of claims 17

18 Thank You! For ICD-10 related questions, please send to: