Icd 10 and icd10 medical policy health plan under hipaa

Health Plan Medical PolicyICD-9 to ICD-10 Transition for Health Plans: Tactical Code Translation vs. Strategic Issues
ICD-10 Medical Management
ICD-10 Medical Policy Remediation
Improvement Opportunities
Prepared by:
No World Borders, Inc.
ICD-10 Consulting Experts
http://www.noworldborders.com and blog http://www.noworldborders.com/blog

ICD-10 and Medical Policy Management
Guiding principals for Care Management
Improve wellness, cost savings, auto-adjudication, etc.
ICD-10 specificity will allow rules to enhance pre-auth and auto-adjudication, improve accuracy and consistency applying policies
ICD-10 Education and Awareness
Develop Criteria for prioritization of Policies to remediate
Base on precise intent and services
Clearly define intent of policy (codable)
Requires increased $, time for policy reviews, expedited approval
lack of staff could slow process
Configure Claims System to reflect intent
Testing adjudication results
Multiple scenarios with each policy
Maintenance of Configurations & Rules
Classify each code as Include, exclude, review
For a complete version of this presentation
Please contact ICD10@noworldborders.com

Measures of Success
Compare adjudication rates pre and post policy implementation
Reduction of manual pre-authorization
Increased % of time allocated to case management
Potential Negative – Increased Medical Loss Ratio

Tools & Resources
Research & evaluate tools to manage policies
Resource for standard clinical policies
Compare to existing policy templates: Aetna, Harvard Pilgrim, etc. policies are available
Implement Policy ICD-10 code reference tool
Chose policies that are best to implement
Top 10, easy to implement and manage
Frequently used
Potential - Outsource for development of policy
Develop Guide or Manual for Policy development.

1. Guiding Principles
Determine Guiding Principals (per Health Plan State law)
Efficient, Economical delivery of healthcare (title 49, Ch. 20 Utah code)
Mission – Trust vs. Competitive payer
Balanced policy to deliver both appropriate care and cost effective care
Address both Clinical, Payment and Operational policy in ICD-10
Benefit:
Incremental – Perm.
Clarity, speeds policy development process
Reduce conflict, reduce re-work
Measure:
Did we complete?

2. ICD-10 Education / Awareness
Deeper understanding of code set and structure
Role based ICD-10 Training
Clinicians, Drafter of Policy, Configurators, Approvers, Case Managers, decision makers
Claims Adjusters, Customer Service, IT
Intro / Overview
Terminology differences ICD-9 to ICD-10
Coding

3. Policy Prioritization Criteria
Criteria for Prioritization of Policies
High dollar (high value) cases
High volume
Opportunity for automation or streamlining process
High margins for providers
Improve downstream processes
Improve outcomes for patients
Existing ICD-9 legacy policies
Build Inventory of existing policies
100 Operational policies
400 Clinical policies
Build Inventory of New Policies (ICD-10)
Analysis of existing claims utilization
Apply Criteria for prioritization
Benefit:
Binary - Temp
Focus
Scope
Utilize resources timely
Measure:
Is it done or not?
Did criteria reduce scope for remediation
Did we apply criteria to Inventory?

4. Clearly Define Intent of Policy
Identify owner responsible for drafting policy
Define policy components and identify whether clinical or payment/ operational
Include Venn diagram to show shared components
Confirm policy format
Clinical validation of applicability
Coding Analyst, testing of configurability
Coordinate linked policies (clinical & operational)
Policy dictionary, consistent terminology (reusable across policies)
Policy governance / approval
Develop best practices for policy writing
Benefit:
Incremental downstream
Permanent
Reduced time to make policies
Measure:
How long does this step take? (per policy)
Track Pre vs. Post

5. Configure policy to reflect Intent
Must link from Policy to codes
ICD-10 Diagnosis
ICD-10 Procedure, CPT, HCPC
System Configurator training
Need way to define codes in System
Services in ICD-10
Procedures in ICD-10
Benefit:
Enable use of policy
Measure:
Time/ resources per policy
Level of re-work required

6. Testing
Create scenarios that can test intent of policy under ICD-10
Owner of test case development
Internal test cases
External test cases
Clinical / pre-authorization
Claims payment
End-to-end testing
Benefit:
Avoid business disruption
Avoid unintended consequences
Measure:
Did it work?
Actual match expected?

7. Policy Maintenance
Policy documents
Table storing Policy link to ICD-10 codes
Standard ICD-10 code tables
System Configurations & Rules

Icd 10 and icd10 medical policy health plan under hipaa

by Michael Arrigo on Aug 29, 2011

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Icd 10 and icd10 medical policy health plan under hipaa — Presentation Transcript