Whitepaper. ICD-10 Transition - Hexaware's Approach for Successful Compliance. Published on: October 2011 Author: Kaustubh Chitnis

Transcription

1 ICD-10 Transition - Hexaware's Approach for Successful Compliance Published on: October 2011 Author: Kaustubh Chitnis Hexaware Technologies. All rights reserved.

2 Table of Contents 1 Need for ICD-10 Transition 1.1 Introduction 1.2 Impact of ICD-10 Transition 1.3 Industry Need 2 Hexaware s Approach for ICD Transition 2.1 Strategy & Design Phase 2.2 Development Phase 2.3 Testing Phase 3 Synopsis Hexaware Technologies. All rights reserved. 2

3 1 Need for ICD-10 Transition 1.1 Introduction On January 15, 2009, Department of Health and Human Services (HHS) released the final rule for the implementation of the International Classification of Diseases - Clinical Modification (ICD-10-CM) & Procedural Classification System (ICD-10-PCS). The ICD-10 implementation deadline is on October 1, Health entities that fail to comply by this date will find their claims rejected and would face cash flow disruptions. The benefits of using ICD-10 codes are manifolds. Few of the benefits are Incorporates significantly greater specificity and clinical information, which results in improved ability to quantify impact of health care services. Improves sensitivity while refining grouping methodologies and reimbursement methodologies. Enhanced ability to conduct consumer health surveillance. Decreases need to include or review supporting documentation with claims. Provides greater room to capture new technology and devices Improves logical structure with clear, consistent definitions The white paper would provide insight on current market trends, different approaches that could be taken for the remediation and how Hexaware would play a role in overcoming the transition challenges 1.2 Impact of ICD-10 Transition Transitioning to ICD-10 shall have tremendous impact on the entire Healthcare spectrum. Broadly the entities that shall be impacted are Payors Benefits & Eligibility Caims Adjudication Claim Edits State Regulations Reimbursement rates EOB, COB Claims History Providers Consumers Medical Managed Medical Records Training Medical Policy Provider Contract Training Utilization Compliance & Reporting Portals EHR Appeals Pre Existing Conditions for individual plans Services Case Disease Pre Certification / Referral Utilization Reports Preventive Care Progams Clinical Data Operations Customer Support Provider Credentialing Medical Policy Claim Administration Regulatory Changes Utilization Review Acturials & Financials Cost and Utilization Trend Analysis Actuarial and Underwriting High Dollar Claim Data Related Modules, Screens and Reports ICD 10 Impact on Healthcare Spectrum Transition to ICD-10 shall not merely be an IT impact but it shall also have impact on business as business rules need modifications, the processes shall need to be redefined and may need to undergo changes, Revenue cycle shall be impacted and moreover the medical polices may need changes, organizations may need to bring in reforms in payments etc. Organizations shall need to make enormous amount of investments in resources, personnel, knowledge acquisition and money for ICD-10 transition. Irrespective of the size of the organizations, they shall need to look for resources with business, technology, program management expertise from the market. Many smaller organizations shall need to opt for outsourcing due to the lack of availability of such resources or plan for change in their business models The first step to successful transition to ICD-10 is to assess the impact of ICD-10 and then strategize and plan for the entire overhaul. Many of the larger Payer organizations like the Blue Cross & Blue Shields have completed their assessment and are in process of implementing the changes. Other organizations are still lagging behind and are in the process of planning the assessment phase for ICD-10 transition. Looking at the current progress, it seems unlikely that these organizations would be able to achieve the compliance by the mandated date. Hexaware Technologies. All rights reserved. 3

4 ICD - 9 to 10 Transition - Hexaware's Approach The HexSOA for Successful Test Model Compliance (HSTM) 1.3 Industry Need Healthcare impacted entities will need to look for accelerators/ tools that would help them achieve ICD-10 transition. A Gartner published report provides details on the various tools available in the industry. The evaluation parameters used by Gartner are Business Assessment, Tools & Tables & Application Remediation. Hexaware capabilities in this area was covered in Gartner s report U.S. Healthcare Payers Should Assess ICD-10 Vendor Capabilities Against Three Issues published by Robert H. Booz & John-David Lovelock dated 31 August 2011 In order to determine the best method for ICD-10 implementation, the organizations should consider and weigh out multiple options. As a part of Remediation, organizations can opt for one of the following strategy Crosswalk Strategy Basic Upgrade Strategy Maximum Upgrade Strategy Upgrade and Crosswalk Hybrid Strategy Regardless of the remediation strategy chosen: Based on the business area, organizations may need to retain the ability to process information using ICD-9-CM codes There will be a period of time where the organization must be able to dual process ICD-9-CM and ICD-10 codes Longitudinal data that spans multiple years will need to be converted to ICD-9-CM or to ICD-10 for trending and other reporting and analysis that spans multiple years depending on the predominance of code type in the data set that is being analyzed Hexaware Technologies. All rights reserved. 43

5 t Whitepaper 2 Hexaware s Approach for ICD Transition Hexaware has built an ICD Assurance Framework that is unique in the marketplace with end-to-end capabilities that facilitates an efficient, effective, and compliant transition. This framework is developed taking in to consideration the challenges the industry is currently facing. Assurance Framework spans across all phases of the Software Development Life Cycle (SDLC) as it applies to the ICD-9 to 10 transition process: Strategy, Design, Development, Testing/Training and Transition. Sample DB SDLC Pre-Assessment Strategy Design Development Testing and Training Transition S Source code GEM Interfaces DB Source code GEM u b s e HPower10 Exec & SME s Input Assessment Timeline HPower10 Exec & SME s Input New Report Requirement Risks [CD 1] Requirements from current situation Development Task List Effort Assessment Development Priorities - Experienced - Development infrastructure - Knowledge Base Detailed Development Plan Best Practices Testing Requirments Business Processes User Roles Manual Testing Automated Testing Training Interfaces Cross Walk Application The overall impact o ICD remediation can be divided as 60% impact on business and 40% on IT. Organizations should carry out a thorough impact assessment to determine the potential size and scope of Transition. Determining how much the current ICD-9 code set is ingrained in your organization s operations and technology infrastructure will be a key indication of how invasive the transformation could be. 2.1 Strategy & Design Phase At the heart of ICD Assurance Framework, Hexaware s HPower10 helps in identifying the impact of transition for Business as well as IT teams. It helps the organizations to finalize their remediation strategy and plan the entire transition process. HPower10:- Provides a quick, thorough, automated impact assessment of all IT systems thus minimizing human errors of oversight or omission that manual assessments are likely to encounter. Manual assessments require the team performing to look for every potential use of ICD-9 codes or references, whereas an automated assessment will run through all potential scenarios in a faster timeframe Identifies business rules that need to be changed Generates out of the box customizable reports that will allow key stakeholders to prioritize and plan the remediation Facilitates detailed impact assessment and transition planning by providing accurate and exhaustive Requirements Reports - Database Changes, Source Code Changes and ICD-9 to ICD-10 Mappings. Enables trend, data analysis and claims data comparison by providing forward and backward crosswalks. Hexaware Technologies. All rights reserved. 5

6 2.2 Development Phase Hexaware proposes 4 different approaches for ICD-10 transition. Based on the identified impacts, development phase could be strategized and executed Crosswalk Strategy Basic Upgrade Strategy Maximum Upgrade Strategy Upgrade and Crosswalk Hybrid Strategy Crosswalk Strategy - Inbound ICD-10 business transactions would be transformed to ICD-9-CM equivalent using reimbursement mappings or crosswalks. The business processes and systems would continue to store ICD-9-CM codes and utilize ICD-9-CM rules, without converting to ICD-10 codes. With this approach, update to internal policies, processes, or systems to accommodate ICD-10 codes is not required. Advantages Lower ICD-10 implementation costs initially Less disruption to business operations and systems initially Disadvantages - It is not possible to take advantage of ICD 10 codes ICD-10 implementation more difficult and costly in the future Difficulty associating ICD-10 code submitted by external partner to information stored in systems Loses specificity of ICD-10 codes and their added granularity Will have to undergo another transition when fully converts to ICD-10 This approach would help to achieve government mandate but will not help in reaping the benefits of ICD10 code sets. Basic Upgrade Strategy Policies, Processes & Modules that need to be converted to ICD-10 would be identified using HPower10 impact assessment. The identified policies, processes, and systems would be updated to ICD-10 using equivalent aggregation. ICD-10 transactions received from business partners would be accepted, stored and processed. Business rules for the identified policies and processes would be updated to utilize some added granularity of ICD-10. ICD-9-CM business rules and policies would be translated to ICD-10 without taking into consideration the full potential benefits of ICD-10 Advantages Systems upgraded to meet minimum business functionality Potential for fewer future transitions than the crosswalk strategy- to the maximum upgrade strategy Disadvantages Does not gain all of ICD-10 benefits Will need to upgrade in the future to fully utilize ICD-10 Could spend extra effort to update same modules twice Maximum Upgrade Strategy - All policies, processes, and systems would be converted to ICD-10. ICD-10 transactions received from business partners would be accepted, stored and processed. ICD-9-CM business rules and policies would be translated to ICD-10 taking into consideration the full potential benefits of ICD-10. Advantages No later conversions would be required thus reduction in future costs More accurate payments based on the greater specificity and granularity of ICD-10 codes Improved reporting and historical data files Disadvantages Initial development costs would be higher Upgrade and Crosswalk Hybrid Strategy - The most frequently used policies; processes and ICD-9 codes would be identified using HPower10 accelerator. These identified processes and policies would be converted to ICD-10.Crosswalk functionality would not be used for these policies and processes. For claims with ICD-10 codes that do not fall into the costly or frequently used category, an ICD-10 to ICD-9 crosswalk would be utilized. Hexaware Technologies. All rights reserved. 6

7 Advantages Lower initial cost than optimal compliance Gains some ICD-10 benefits Disadvantages Difficult to identify all interrelationships at the beginning of process Would need to transition the rest of the policies, processes, and systems at a later date 2.3 Testing Phase ICD-10 will require extensive testing due to the magnitude of business and system modifications. All the impacted systems must be tested to ensure all the internal systems and external trading partners are ready to accept the new code sets. It is of utmost importance to strategize testing for ICD-10 transition with robust test solution. The solution should be a combination of a well-defined Testing life cycle and processes that leverage accelerators to speed up the testing effort. Hexaware s testing approach using its accelerator is shown below Discover Perform impact analysis using HPower10 Create detail Test strategy based on the exhaustive reports provided by HPower10 Understand customer specific business processes and customizations if applicable Design and Customization Execution Create manual /automation regression test suite across all test beds available for various business processes Create/Modify customer specific test cases and data with help of SME s (Physicians, Clinical Practitioners) Support setup of test infrastructure. Integration of test cases with your test tools like HP QC Internal /Independent Testing (Performance testing, Vertical and Horizontal testing) Parallel testing (Perform functional testing at various stages of transition for ICD-9 and ICD-10) External testing (Trading partners, Payers, Clearing houses) EDI (835, 837) transaction testing Reporting Review test results at regular check points during transition Optimize test plan, cases as required based on business feedback ICD-10 Testing Methodology The impacted areas identified during the Strategy & Design Phase using Hexaware s accelerator - HPower10 would help to identify specific Test Scenarios and create Test data required for Testing; thus expediting the overall testing process by 25-30% Hexaware Technologies. All rights reserved. 7

8 3 Synopsis Healthcare entities across the spectrum would be impacted with the ICD-10 transition. For the successful transition, there is no single full proof solution or an approach. Every impacted entity would need to chalk out their remediation strategy. The entire ICD-10 overhaul should be divided into small projects. It would require huge amount of resources and investment. Healthcare entities would need to look for accelerators available in the industry and also acquire experienced resources for the transition. In case the ICD transition is not strategized, planned and executed properly, the organizations are expected to face Cash flow disruption Productivity loss Increased claim rejections Increased Revenue Cycle Payer Provider relationship To overcome the above challenges, Hexaware has developed an ICD Assurance Framework. It provides following Benefits Get an end to end solution to transition from ICD-9 to 10 Reduce risk of human judgment effort through use of automated mapping options Save 50-60% time over a manual transition through use of automated evaluation algorithms Simplify transition through a 10-15% reduction in ICD 10 mapping options Highlight key issues through analytical reports on high-volume or high-dollar codes Conserve internal IT bandwidth. The existing IT team will be able to focus on executing relevant aspects of the transition Leverage automated testing development for Facets, MetaVance, and similar systems and integration points Receive nearly automatic creation of high-impact training components based on a cross reference of data, tests and user roles Utilize HPower10 for a host of technology platforms, since the tool is platform agnostic Thus Hexaware with its innovative approach, technical and domain expertise would help the ICD-10 remediation. To learn more, visit Address 1095 Cranbury South River Road, Suite 10, Jamesburg, NJ Main: Fax: Disclaimer Contents of this whitepaper are the exclusive property of Hexaware Technologies and may not be reproduced in any form without the prior written consent of Hexaware Technologies. Hexaware Technologies. All rights reserved. 8