Managing The Conversion To HIPAA 5010 No World Borders Webinar by Mike Arrigo

Managing the Conversion to HIPAA 5010 Webinar November 30, 2009 1:00pm EST Mike Arrigo Managing Partner, CEO No World Borders, Inc. For more details, assessment info [email_address] (Please send from your payor or provider email domain address) http://www.noworldborders.com/HIPAA5010MigrationServices.html

Topics
Process impact
Organizational impact
Requirements audits
Testing
Planning
Organizational readiness
http://www.noworldborders.com/HIPAA5010MigrationServices.html

HIPAA 5010 Implementation Approach
Business and IT Alignment – Business, technology, strategies, and resources must be aligned to achieve results.
Best-Practices Measurement – Best practice methods, and frameworks such as CMM & ITIL
Process Change and Innovation –Working with people and helping them see a better way to work.
Manage Expectations, find quick wins
Help the team Visualize the process to improve buy-in
Change Management & Communication – Communicate and distribute critical business knowledge, share the “wins” via social media

HIPAA 5010 Process Impact http://www.noworldborders.com/HIPAA5010MigrationServices.html

“ Forced” Benefits of 5010 More than a Means to An End : ICD-10
Organizational coordination, “de-siloization”
Review of trading partner process, integration
Acknowledgements
Regulatory impacts
Testing
Early look for places that electronic claims “drop to paper”

Impact of 5010 & ICD-10 on Process http://www.noworldborders.com/HIPAA5010MigrationServices.html Customer Service Product Development Revenue Management Reimbursement Management Finance & Administration Care Management Network Management Risk Management Member Services New Benefits Design Enrollment Claims Accounting Disease & Case Management Provider Contracting Rating Provider Services Product Setup & Configuration Billing & Receivables Fraud Detection Human Resources Utilization Management Network Management Underwriting Employer Services Billing Reconciliation Medicare/ Medicaid Financial Extracts Disease Management Claims Repricing Actuarial Broker Services Care Management Population Management

Visualize Current & Future To Ensure Alignment, Value http://www.noworldborders.com/HIPAA5010MigrationServices.html Claims Process Enterprise Infrastructure Services (Mainframe legacy, Portal, SOA, IDRS, LDAP, EAI, E-mail, IT Operations) Customer Service Product Dev Care Mgmt Revenue Mgmt Reimb Mgmt Finance SFA Prodict LMS Inv MGMT B2B product ERP. SCM productinfo. MES DB ERP CRM BPM models, simulates, executes, manages, monitors, & optimizes those Business Processes. Customer Service Product Development Care Management Revenue Mgmt Reimbursement Management Finance & HR SFA Product LMS Inv MGMT B2B Enterprise Infrastructure Services (Mainframe legacy, Portal, SOA, IDRS, LDAP, EAI, E-mail, IT Operations) product ERP SCM product MES DB ERP CRM Organizational Units Real-World Business Processes span organizations, systems, and applications. Product Offerings to Members Claims Management Customer Services Processes

Example Process Simulation http://www.noworldborders.com/HIPAA5010MigrationServices.html

Example Process Model Artifact http://www.noworldborders.com/HIPAA5010MigrationServices.html

Where to Apply Process Models
Ideal projects
Exception Handling (systems handle some work, people must deal with exceptions)
Corporate re-structuring, turn arounds
Best Practices (Process Excellence, Compliance)
Entry Point for Claims Upgrade Engagements
Significant Human Interaction

HIPAA 5010 Organizational Impact http://www.noworldborders.com/HIPAA5010MigrationServices.html

Understanding Stakeholder Impacts
Health Plan Staff
Providers
Employers
Members
Vendors
Regulatory Agencies

What is the IT Orientation & Approach to 5010?
Enterprise approach
Receiving
Archiving
Validating
Transforming
Routing
Federated claims system (legacy) issues
System type (custom built, vendor customized)
Age & architecture of system (mainframe, SOA…)

HIPAA 5010 Requirement Audits http://www.noworldborders.com/HIPAA5010MigrationServices.html

Audit Capabilities Check List: Regulatory Experience & Judgment
Understand unique architecture and business organization
Perform review of business requirements & artifacts
Provide a detailed regulatory gap analysis between:
HIPAA 5010 Final Rule and X12 Implementation Guides for HIPPA 5010 covered transactions and acknowledgements)
System (i.e., receiving, archiving, validating, transforming, processing and responding)
Facilitate defining the steps to complete 5010 Functional Specifications

HIPAA Transactions Experience
HIPAA Transactions Experience:
820, 834, 835, 837 P, 837 I, 837 D, 270/271, 276/277 and 278 transactions and the 999,
Acknowledgements
TA1
277CA

Impact of HIPAA Title II, Subtitle F With Respect to 5010 EDI Standards
Privacy & Security
Transactions
Code sets
Identifiers
Trading partner security & governance risk assessments

HIPAA 5010 Testing http://www.noworldborders.com/HIPAA5010MigrationServices.html

Testing Will Be Critical . . . http://www.noworldborders.com/HIPAA5010MigrationServices.html

System Inventory, Test & Transition Plan (Sample Artifact) http://www.noworldborders.com/HIPAA5010MigrationServices.html

Detail Test Framework (Sample Artifact) http://www.noworldborders.com/HIPAA5010MigrationServices.html

HIPAA 5010 Planning http://www.noworldborders.com/HIPAA5010MigrationServices.html

Planning – Do Not Underestimate
Dec. 31, 2010, payers and providers complete first level testing
Conduct internal testing throughout 2010
Once you realize that Level Two testing must be completed by the end 2011, final compliance dates are not so far away

Planning: Identify Principles for Stakeholder Interaction
Address 4010 to 5010 cutover issues
Review current applications, IT projects
Design approach
Impacted systems
Vendors
Members
Providers
Requirements development & audit
http://www.noworldborders.com/HIPAA5010MigrationServices.html For detail plan in 15 PowerPoint Slides, Contact us

HIPAA 5010 Organizational Readiness http://www.noworldborders.com/HIPAA5010MigrationServices.html

Achieving 5010: Organization Perspective http://www.noworldborders.com/HIPAA5010MigrationServices.html

Organizational Readiness Checklist Overall Industry Expertise (1 of 2)
Visibility with and involvement in industry groups that shape the standards and their adoption timeframes
Ensure a “vendor agnostic” approach (not only tools, software)
Experience with multiple Health Plans, specifically with HIPAA Transactions (Blue Exchange, ITS etc.)
Vendor claims system experience
Transaction Management systems
X12 Transactions and Acknowledgements expertise
Understand TR3 implementation guides
http://www.noworldborders.com/HIPAA5010MigrationServices.html For Bios & Detail Capabilities Contact Us

Organizational Readiness Checklist Overall Industry Expertise (2 of 2)
HIPPA 4010a and HIPAA 5010 regulatory requirements expertise
WEDI experience (an industry standards organization for EDI transactions)
Understand WEDI/NCHICA 5010 implementation timeline
CMS, ICD-9 and ICD-10 experience to understand global “end game” ramifications
http://www.noworldborders.com/HIPAA5010MigrationServices.html For Bios & Detail Capabilities Contact Us

Most Payers & Providers Are Under Estimating the Joint Requirement & Analysis Time for 5010 and ICD-10
Establishing organizational structure
Planning to replace, upgrade your claims system
Secure compliance attestation from clearing houses
Review process impacts and improve process
Developing scoping and requirements documents

Market Intelligence
Laggards
Lack of business & IT alignment
CIO short term budget concerns
Just getting started in understanding the landscape of vendors and approaches
Leaders:
Working to beat deadlines
Investing heavily in process, people, systems
Challenged by legacy issues
Intent on outsourcing claims processes for laggards, at a profit

Prediction Based on Experience
Most large IT projects fail on the first attempt
Usually, the cause is lack of business & IT alignment
Difficult to balance day to day with innovating new business value via IT
Talent management plans are an after thought
Suggestion for 5010 success : Make an early investment in outside professional guidance on these and other issues identified

Mike Arrigo Managing Partner, CEO No World Borders, Inc. For more details, assessment info [email_address] (Please send from your payor or provider email domain address) http://www.noworldborders.com/HIPAA5010MigrationServices.html

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Managing The Conversion To HIPAA 5010 No World Borders Webinar by Mike Arrigo

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Managing The Conversion To HIPAA 5010 No World Borders Webinar by Mike Arrigo — Presentation Transcript