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Neutrality Reimbursement and Encouraging Rapid Claim Settlements in ICD-10
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Neutrality Reimbursement and Encouraging Rapid Claim Settlements in ICD-10

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The ICD-10 migration has revealed that the change in diagnosis-related grouping …

The ICD-10 migration has revealed that the change in diagnosis-related grouping
(DRG) codes will have severe financial and operational impacts on Healthcare
providers. A provider’s success will be determined by a streamlined ICD-10 migration
and aversion of any regulatory risks.
One of the greatest financial risks lies with claim reimbursements, where there will be a
variation in payer settlements for a medical condition treated and coded in ICD-9, compared
to the same in ICD-10, leading to discrepancies in settlements.

Published in: Health & Medicine

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  • 1. Achieving Reimbursement Neutrality andEncouraging Rapid Claim Settlements in ICD-10 CHALLENGES The ICD-10 migration has revealed that the change in diagnosis-related grouping FACED IN CLAIMS (DRG) codes will have severe financial and operational impacts on Healthcare REIMBURSEMENT providers. A provider’s success will be determined by a streamlined ICD-10 migration and aversion of any regulatory risks. • Medical coding – One of the greatest financial risks lies with claim reimbursements, where there will be a Identifying appropriate ICD- variation in payer settlements for a medical condition treated and coded in ICD-9, compared 10 codes, based on rules to the same in ICD-10, leading to discrepancies in settlements. and preferences defined in the provider’s guidelines for The discrepancies in these settlements can lead to inaccurate underpayments or overpaid medical coders reimbursements from payers for services rendered by providers. To avoid disputes, discrepancies and • Medical billing –Improper patient discomfort, providers should select an IT partner who can assist them in overcoming these rule definitions will impact challenges. reimbursements, rendering business edits remediation Syntel’s Solution critical • Denial management – Syntel’s nSure10SM Reimbursement Risk Analysis Services enable providers to assess the Increased claim processing effect of ICD-10 migration on future revenues, allowing them to mitigate risks and minimize losses. time due to a large volume Our in-built tools ensure a smooth operational workflow and allow you the dual advantage of of denials, appeals and functional and financial stability throughout the ICD-10 migration process. pending claims Our team of domain experts and technical analysts use a unique six-phase reimbursement neutrality • Contract management methodology to assess a provider’s reimbursement risk: – Payer contracts may have to be renegotiated to Syntel’s Reimbursement Neutrality Methodology mitigate the risk of under/ over reimbursement Data Extraction Data Formatting Data Sampling • Adjustments to reimbursements – Identify data sources Syntel’s Format iTAP framework: Reimbursement amounts Billing for RN Analysis Converter: •Data selection based •Data transformation on business criteria are based on the severity Data of diagnosis, and analysis •Data uploading is required to understand changes in Health Plan coverage and cash flow which may require future adjustments Data Analysis Data Simulation Data Prioritization • Pay for performance Syntel’s Reporting : Syntel’s Comparator Data : – Incentives from payers •Analytics demonstrat- & iTAP: •Prioritize simulated and governing bodies for ing variance •ICD-10 sample data data analysis based on various treatments and generation business parameters linked reimbursement •Determine cost weight for ICD-19 and ICD-10 schemes will be affected Analytical Reports This assessment would include the following features: Remittance Advice (RA) Analysis – Remittance-oriented analytics assist in evaluating claim decision information, and review adjustments for improving and optimizing the provider’s claim submission process Medicare Payment Analysis – Investigating exceptional medical cases, where the expenses of services vary from standard rates, may prove useful in reviewing contracts Hospital-acquired conditions (HAC) based claims - Claims scrutiny, based on HAC indicators, highlight reimbursement losses and assist in verifying operational efficiency measures Financial Neutrality reports – A set of financial analysis reports, referenced to DRG amounts, billed amounts, reimbursed amounts and net reimbursement amounts, serves as a platform to foresee reimbursement gaps
  • 2. Achieving Reimbursement Neutrality and Encouraging Rapid Claim Settlements in ICD-10WHY SYNTEL? • A leading global IT and KPO service provider • Established in 1980 (NASDAQ: SYNT) • More than 24 offices in North America, Europe and Asia • Flexible onsite-offshore global delivery model • Dedicated Centers of Excellence (CoEs) to help clients with expert advice and project guidance • World-class services and tools to enable, enhance and integrate the payer-provider relationship in the Healthcare industryBUSINESSBENEFITSThis analytical approach willbenefit Providers by enabling: • Support for intelligent decision-making through comprehensive reimbursement variance reports and dashboards • Risk measurement through granular reports with causal analysis to depict payment variations • The ability to leverage historical billed data and conduct an in-depth analysis • Simulation of ICD-10 billing data in a controlled Screenshot of the Neutrality Testing Reports environment, based on ICD- 9 data • Processing of ICD- Salient Features of the nSure10SM Solution 9 and ICD-10 billed data, to generate gross • A robust ICD-10 financial risk analysis and modeling framework, with a defined approach reimbursements as per DRG and accelerators assignments • Automated sampling and prioritization of test data, through set parameters and in-built scientific • Comparison of two algorithms using Syntel’s iTAP Test Data Management tool references for verifying • Embedded DRG Grouper for variance calculation the variance in the reimbursement • Customizable approach to suit specific organizational frameworks • In-house medical records to • Simulator testing platform for test execution, through Syntel’s Neutrality Simulation Lab conduct the simulation and • Volume data generation through test data management, integrated with crosswalk for automatic complete the risk analysis ICD-9 to ICD-10 billing data conversion For more information, visit Syntel online at www.syntelinc.com or call us at US/ +1 (248) 619-3503 UK/ +44 (0) 207-636-3587 © 2013, SYNTEL INC. 022013

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