At the End of the Day Does the Pipeline Deliver: Cerner / WellPoint ICD-10 Pilot Test Collaboration

Transcription

1 At the End of the Day Does the Pipeline Deliver: Cerner / WellPoint ICD-10 Pilot Test Collaboration Elaine O Bleness MBA, RHIA, CHP, AHIMA-approved ICD-10 CM/PCS Trainer Cerner Revenue Cycle Executive June 18, 2013

2 Overview 1. WellPoint Background 2. Cerner Background 3. WellPoint Test Approach 4. Cerner / WellPoint Test Collaboration

3 WellPoint Background

4 WellPoint Background WellPoint provides health insurance for over 34 million members WellPoint is a Blue Cross Blue Shield licensee holder for all or portions of 14 states Brand name in these states are Anthem Blue Cross Blue Shield, Anthem Blue Cross, Empire BlueCross BlueShield, Blue Cross and Blue Shield of Georgia States include ME, NH, CT, NY, VA, GA, IN, KY, OH, MO, WI, CO, CA, NV Lines of business in health insurance include Commercial, Medicare, and Medicaid

5 Cerner Background

6 Cerner Background For more than 30 years, Cerner has been executing its vision to make healthcare safer and more efficient Cerner offers a comprehensive array of clinical and revenue cycle management information software, professional services, medical device integration, remote hosting and employer health and wellness services Licensed by approximately 10,000 facilities around the world, including more than 2,700 hospitals, 4,150 physician practices, 550 ambulatory facilities, 800 home health facilities and 45,000 physicians

7 Government Recommended ICD-10 Timeline Mar 1 13 Dec Apr 13 June 13 Oct 13 Jan 14 Jan 1 14 Apr 1 14 October 1, 2014 Start conducting high-level training on ICD- 10 for clinicians & coders Start testing ICD- 10 codes and systems with your practice s coding, billing and clinical staff. Begin testing claims and other transactions using ICD-10 codes with business trading partners Review coder and clinician preparation; begin detailed ICD 10 coding training (6-9 months) Complete ICD-10 transition, monitor systems and correct errors ICD-9 codes continue to be used for services prior to Oct. 1, 2014 ICD-10 codes required for services after Oct. 1, 2014

8 WellPoint Test Approach

9 Focus of WellPoint s Collaborative Test Approach -Business Continuity Test Goal Safeguard Business Continuity Pillars of Continuity Cost of Care Admin Cost MTM Corporate Controls Implications Evaluating the outcomes of each pillar is central to safeguard WellPoint, and thus our Provider, Vendor, and Data Trading Partners - this burden falls on ICD-10 End to End Testing. With the scale of ICD-10, End to End External testing is a new discipline of unprecedented complexity

10 Assuring Readiness for ICD-10: Internally and Externally Objectives 1. Reduce ICD - 10 Implementation risk for WellPoint WellPoint business continues without increase in rejected files in EDI from External Partners (Providers and Data Trading Partners) All High Risk High Profile Vendors are fully ready to support ICD Avoid Provider abrasion and adverse impact to business Providers do not experience delays in service/payment due to rejected files. Provider awareness, readiness and execution is increased Expected Outcomes 1. Test plans established that assure both WellPoint Internal Readiness and External Partner Readiness 2. After External Data Trading Partners complete their implementation, testing is initiated with WellPoint to assure they can generate and submit files without delays in business processes. Early feedback on testing defects increases their readiness and preparation. 3. All High Risk, High Profile Vendors and High Value, High Volume Data Trading Partners are tested end to end prior to 10/1/2014 to validate that critical business processes will function. 4. Plan put in place to allow detailed analysis and coordination of external partner readiness and file interface detail, which will allow staggered testing schedule and exposure of early defects.

11 Key Test Focus 1. Focus on Corporate Continuity 2. Vendor and Data Trading Partner Testing Keys: Early identification of defects Test high risk, high profile vendor and data trading partners Initiate true End to End claims scenario testing for vendors Testing will include Business testing review 3. Provider Testing Keys: Targeted testing to High Risk groups and High Risk Scenarios Provider Collaboration needed for both Provider and Payer work to gain insight into more realistic outcomes vs. manufactured outcomes (both parties can leverage this insight in other relationships) Testing will include business impact reviews (Reimbursement, Medical Management, Benefits) Include true end to end claims scenario testing for Provider Testing

12 Cerner / WellPoint Test Collaboration

13 Background and Opportunity Benefits to WellPoint: Benefits to Cerner: Cerner has 18 percent of EMR market, WellPoint has in excess of 268,000 providers, partnership allows positive proactive market influence and early insight into outcomes Ability to completely E2E test WellPoint processes and effectiveness of mapping strategy, ICD-10 Code Impacts and Cerner EMR Products Provide early assurance that claims can process successfully through full ICD-10 path from provider to payer Insight into reimbursement impacts between 9 and 10 Provide early assurance that claims can process successfully through full ICD-10 path with payer Create marketable service for providers to increase their ICD-10 readiness Provide market assurance of ICD-10 readiness of Cerner products Gain insight into effectiveness of mapping strategy used within clinical products Working together ahead of compliance, WellPoint and Cerner have the opportunity to dramatically improve post-compliance outcomes. Insight gained now will financially and operationally benefit both organizations once ICD-10 is in effect.

14 Moving Upstream: Gain Insight into ICD-10 Lifecycle Conduct pilot with Cerner to gain insight into the first steps of the ICD-10 process through ICD-10 Modeling Patient Visit: Provider documents visit in EMR and assigns ICD-10 code Final Code Assignment: Medical coder reviews and validates ICD-10 code Claim File: Claim file generated. Submitted directly or to clearinghouse Clearing House: Claim file is formatted for transmission to WellPoint Claim Processed by WellPoint New Model: External Testing Traditional Testing: Internal to WellPoint

15 Moving Upstream: Gain Insight into ICD-10 Lifecycle Conduct pilot with Cerner to gain insight into the first steps of the ICD-10 process through ICD-10 Modeling Patient Visit: Provider documents visit in EMR and assigns ICD-10 code Final Code Assignment: Medical coder reviews and validates ICD-10 code Claim File: Claim file generated. Submitted directly or to clearinghouse Clearing House: Claim file is formatted for transmission to WellPoint Claim Processed by WellPoint New Model: External Testing Traditional Testing: Internal to WellPoint Test Pilot with Cerner: Allows testing of the first steps in ICD-10 lifecycle Why Cerner? 2 nd largest EMR vendor with 18% of market share WellPoint has 268,000+ physicians many of which use Cerner products for EMR, medical coding and revenue cycle management Cerner has expressed early interest in collaborating with WellPoint on business continuity testing

16 Moving Upstream: Gain Insight into ICD-10 Lifecycle Conduct pilot with Cerner to gain insight into the first steps of the ICD-10 process through ICD-10 Modeling Patient Visit: Provider documents visit in EMR and assigns ICD-10 code Final Code Assignment: Medical coder reviews and validates ICD-10 code Claim File: Claim file generated. Submitted directly or to clearinghouse Clearing House: Claim file is formatted for transmission to WellPoint Claim Processed by WellPoint New Model: External Testing Traditional Testing: Internal to WellPoint Test Pilot with Cerner: Allows testing of the first steps in ICD-10 lifecycle What is the status of the pilot? WellPoint and Cerner have defined scope of pilot and engaged resources Providers and Hospitals have been identified and initially engaged in pilot test planning Test plans are being finalized and timelines confirmed to begin testing in 4Q2013

17 Moving Upstream: Gain Insight into ICD-10 Lifecycle Conduct pilot with Cerner to gain insight into the first steps of the ICD-10 process through ICD-10 Modeling Patient Visit: Provider documents visit in EMR and assigns ICD-10 code Final Code Assignment: Medical coder reviews and validates ICD-10 code Claim File: Claim file generated. Submitted directly or to clearinghouse Clearing House: Claim file is formatted for transmission to WellPoint Claim Processed by WellPoint New Model: External Testing Traditional Testing: Internal to WellPoint Test Pilot with Cerner: Allows testing of the first steps in ICD-10 lifecycle High level goals of pilot: Phase 1:Test technical functionality processing ICD-9 claims data with Cerner acting as the provider Phase 2: Test technical functionality processing ICD-10 claims data with Cerner acting as the provider Phase 3: Process natively coded ICD-10 claims data with providers and assess results

18 Cerner Pilot Test Conduct pilot with Cerner to gain insight into the first steps of the ICD-10 process through ICD-10 Modeling Phase 1 Phase 2 Phase 3 Test ICD-9 baseline codes with Cerner acting as the provider Ensure the technical aspects of the test are working as planned prior to engaging the provider Cerner will generate claims using their Optum Insight tool WellPoint will process the claims in a controlled environment WLP will return the appropriate documentation to Cerner for review

19 Cerner Pilot Test Conduct pilot with Cerner to gain insight into the first steps of the ICD-10 process through ICD-10 Modeling Phase 1 Phase 2 Phase 3 Test ICD-10 codes which may be manually generated with Cerner acting as the provider Follow the same process and outcomes as in Phase 1

20 Cerner Pilot Test Conduct pilot with Cerner to gain insight into the first steps of the ICD-10 process through ICD-10 Modeling Phase 1 Phase 2 Phase 3 Engage Providers to process natively coded ICD-10 claims and assess results Engage Clearinghouse to process claims Generate claims utilizing Cerner revenue cycle solutions WellPoint will analyze claims outcomes and provide appropriate feedback to Providers, Clearinghouses and Cerner

21 Most Important Takeaway There are Two Simple Rules Emerging for Collaborative Testing 1. Manufactured ICD-10 data will only give directional insight into behavior of claim adjudication, reimbursement, and analytics 2. Real data shared between Data Trading Partners, Providers and Payers is the only way to predict reimbursement shifts and continuity in operations

22 Next Steps and Recommendations Lessons and Takeaways from Collaborative Testing Identify trading partners that want to do testing Identify solutions to be included Start Phase 1 Testing of ICD-10 Move through timeline to start Phase II Participate in HIMSS-WEDI National Pilot Program

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