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Icd 10 implementation and business final slideshare

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icd-10 is an enterprise wide challenge for health plans and health care providers. Our firm has performed ICD-10 work for companies across the U.S.

icd-10 is an enterprise wide challenge for health plans and health care providers. Our firm has performed ICD-10 work for companies across the U.S.

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Icd 10 implementation and business final slideshare Icd 10 implementation and business final slideshare Presentation Transcript

  • ICD-10 The Different Dimensions of Business Continuity Planning Presented by Mike Arrigo Managing Partner, No World Borders [email_address] July 21, 2011 WEDI Implementation Forum Advancing Down the Implementation Highway: Merging into 5010 Compliance, Shifting into ICD-10 http://www.noworldborders.com
  • More About Us http://www. noworldborders.com
    • Ten years of success with payers, providers, pharmaceutical and medical device companies
    • Success stories
    • More about our ICD-10 approach
    • Nationally recognized experts
      • HIPAA 5010 and ICD-10
      • Meaningful Use
      • Medicare Advantage Quality Measures (HEDIS, Star Ratings, CMS VBP)
      • Process improvement
      • Claims systems
    • Private equity backed
    http://www.noworldborders.com
  • ICD-10 BCP Topics
    • Three constraints for ICD-10
    • Five principles of BCP and ICD-10
    • Five dimensions, 25 risk areas
    • Post mandate risks for ICD-10
    • Opportunities with ICD-10
    • Next Steps for ICD-10 implementations
    http://www.noworldborders.com http://www. noworldborders.com
  • Unique Challenge of ICD-10 Three Constraints, Single Compliance Date Compliance Iteration & Innovation Vs. http://www.noworldborders.com
  • Five Principles of BCP http://www.noworldborders.com Business Impact Analysis Plan Development & Execution BCP LIFE CYCLE Test Plan Maintenance Plan Business Impact Analysis Risk Assessment Strategy Selection Plan Development & Execution
  • Business Continuity Planning for ICD-10 For a complete slide presentation, please contact No World Borders [email_address] http://www.noworldborders.com Business Impact Analysis Plan Development & Execution ICD-10 BCP LIFE CYCLE ICD-10 Testing Post Live 10/1/2013 Support High Level Review, Gap Analysis ICD-10 Risk Assessment ICD-10 Business Impact Assessment ICD-10 Business Roadmap & Strategy ICD-10 Implementation Plan
  • Risk Mitigation
    • Risk identification & trigger events
    • Risk Mitigation Planning
    • Examples of the 5 dimensions, 25 Risk Areas
    http://www.noworldborders.com http://www. noworldborders.com
  • The 5 to 6 Risk Areas
    • Payor Perspective (5)
    • Governing bodies
    • Submitter (clearinghouse, providers, testing, contracting, etc.)
    • Payors (inter-plan partners, payor to payor COB, Out of Network, CMS crossover, worker’s comp, life…)
    • Internal (org change, roadmap, governance, clinical, actuarial, UM, CM, IT, ops, etc.)
    • Operational stabilization (post 10/1/2013 go-live)
    • Provider Perspective (6)
    • Governing bodies
    • Patients (workflow: intake, assessment, coding, documentation, referral, discharge, billing, collection, EMR)
    • Payors (contracting, testing, etc.)
    • Internal (org change, physician outreach & education, coders, UM, CM, roadmap, governance, clinical, IT, ops, etc.)
    • Operational stabilization (post 10/1/2013 go-live)
    http://www.noworldborders.com
  • ICD-10 Key Risks (page 1 of 3) Excerpts from 25 Risk Assessment Areas http://www.noworldborders.com Risk Risk Trigger Event Remediation / Mitigation HealthCo staff are not trained in ICD-10 impacts Training evaluation shows lack of knowledge (by 12/31/2011). Retrain as necessary Providers are not ready to submit ICD-10 codes Provider assessments and external testing show lack of provider preparedness.
    • Assure systems can handle ICD-9 for post 10/1/2013 services/prepare business continuity plan
    • Work with ClearingHouseX and others to move providers forward
    Vendor readiness / capabilities don’t meet SLAs Vendors do not deliver ICD-10 ready products by agreed upon date or do not provide the appropriate functionality.
    • Look for alternative vendors
    • Develop in house capability
    • Negotiate acceptable revised dates and monitor
    • Dashboard of delivery dates
  • ICD-10 Key Risks (page 2 of 3) Excerpts from f 25 Risk Assessment Areas For a complete slide presentation, please contact No World Borders [email_address] http://www.noworldborders.com Risk Risk Trigger Event Remediation / Mitigation Payor financial risk – payments are significantly higher than anticipated Benefit payments for post Oct. 1 2013 services from Oct. 1 – Dec. 31, 2013 significantly higher than anticipated and impact HealthCo ability to pay.
    • Assure sufficient cash reserves prior to Oct 1, 2013
    • Possibly acquire line of credit
    • Negotiate contingencies with providers
    • Understand changes to DRGs, Case Rates, APGs
    Provider financial risk – reimbursements are significantly lower than anticipated Benefit payments for post Oct. 1 2013 services from Oct. 1 – Dec. 31, 2013 significantly lower than anticipated and impact provider’s ability to operate as a business.
    • Communicate with payors to prepare for this
    • Negotiate contingencies with payors
    • Negotiate for periodic interim payments
    • Contracting calendar
  • ICD-10 Key Risks (page 3 of 3) Excerpts from 25 Risk Assessment Areas For a complete slide presentation, please contact No World Borders [email_address] http://www.noworldborders.com Risk Risk Trigger Event Remediation / Mitigation
    • HealthCo productivity reduced due to ICD-10
    • May see increase in paper claims.
    • As of 12/31/13, HealthCo worker productivity and claims processing turnaround significantly impacted.
    • Increase in claims backlog and payment delays.
    • Prepare for additional hiring, at least temporarily
    • Determine causes of slowdowns and revise processes as necessary
    • Conduct virtual operational testing to assess productivity issues prior to go-live
  • Mitigate Vendor Impacts
    • Don’t assume “ICD-10 Compliant” vendors have solved all of your problems
    • Vendor testing
      • SLAs – do they support your test cycle and break / fix approach?
      • Release dates?
      • Include vendors in end to end business test plan
    • Dashboard the collisions and conflicts in release dates, interdependencies
    http://www.noworldborders.com
  • Example: Project Dashboard Risk: ICD-10 Vendor Impacts T OCT 837 JAN 835 APR 834 NOV 999 FEB 270/271 MAY 278 TESTING NOV TA1 MAR 276/277 JUN 820 DEC 277CA Qtr 4 Qtr 2 Qtr 1 Qtr 4 Qtr 3 Qtr 2 Qtr 4 Qtr 3 Qtr 2 Qtr 1 Qtr 1 Qtr 3 Analysis -> ICD-10 Implementation -> Testing -> Go-Live Qtr 3 HealthCo provider lookup System Upgrades Prod 01/2012 4010 -> 5010 Migration Vendor A Vendor B Vendor C Vendor D prod 1 Vendor D, prod 2 Veendor D, prod 3 Vendor X, RFP Vendor E Vendor Y(RFP?) Vendor F Vendor G For a complete slide presentation, please contact No World Borders [email_address] http://www.noworldborders.com
  • Example of Post October 1, 2013 Issue ICD-10 Updates
    • At ICD-9-CM Coordination & Maintenance Committee Meeting (9/15/10) partial freeze for both ICD-9-CM and ICD-10-CM
    • On 10/1/2014 - updates to ICD-10 will begin
    For a complete slide presentation, please contact No World Borders [email_address] http://www.noworldborders.com
  • Example of ROI Items (page 1 of 2) Real World Examples For a complete slide presentation, please contact No World Borders [email_address] http://www.noworldborders.com Opportunity Benefit or Recommendation
    • Research ability to change reimbursement method from percent of billed charges to using DRGs based on ICD-10.
    • Need to capture ICD-9 now and ICD-10 in the future.
    • Better visibility into services being rendered and analysis of charges against industry standards.
    • Capturing ICD-10 codes will also deliver valuable information for improving wellness programs, which translates into health cost savings.
    • Overall risk and issue identification from ICD-10 initial review.
    • HealthCo staff had meaningful take-aways.
    • Knowledge sharing took place between teams.
    • Medical Management team responded with interest in developing improved health risk identification systems based on new ICD-10 codes.
    • Training team will begin discussions on viability of current systems and materials to support new ICD-10 training.
  • ROI Items Identified (page 1 of 2) Real World Examples For a complete slide presentation, please contact No World Borders [email_address] http://www.noworldborders.com Opportunity Benefit or Recommendation
    • Raised executive awareness of ICD-10 project impacts and resource challenges.
    • Presented organizational tool that will be given to HealthCo as part of project.
    • Oversight committee better prepared for handing two major projects (5010 & ICD-10).
    • Business Roadmap sessions delivered executive level education on developing organizational initiatives.
    • Repeatable process for planning prioritization.
    • Efficiencies so senior management direction given to execution team
    • Ensures team is aligned with and working toward organization goals
    • Awareness of opportunities and innovation with ICD-10
    • Next Steps
    http://www.noworldborders.com
  • Mapping Observed Changes For a complete slide presentation, please contact No World Borders [email_address] http://www.noworldborders.com Before Assessment During Assessment Remediation Plan thru October 1, 2013
    • While HealthCo made great strides in the last 90 days, the organization must continue forward progress.
    • HealthCo had low awareness of impact and opportunities of ICD-10.
    • Too many answers were in the “Don't Know” category in the web survey.
    • Urgency for change appeared quite low.
    • Communication levels re: ICD-10 seemed to be very low.
    Ensure regular project management, governance, and requirements development activities are initiated immediately. These activities must be reviewed monthly and quarterly, with regular management oversight. Failure to start these activities will result in regression to where the organization was in August 2010. Training plans as recommended should be prioritized by functional area.
    • Continue Business Roadmap activities for areas not yet prioritized:
    • Plan
    • Prioritize
    • Prerequisite plan
    • Implementation plan for prioritized items
    • Overall ICD-10 Implementation :
    • Steering committee meeting schedule
    • Establish project management coordination group
    • Establish implementation team org chart, team roles,
    • Recruit, retain, identify team members
    • Iterative review and editing of the project timeline
    • Determine ICD-10 work coordination process:
    • Frequency of communication, coordination of issues
    • Project governance and standards
    • Development and review of requirement artifacts
  • Training as a Risk Mitigation Strategy Example of Business Areas to Train
    • Medical Management
    • Actuarial
    • Benefit coverage
    • Payment policies
    • Payor / Provider Relations
    • Claims processing
    • Statistical trending
    • Fraud and Abuse
    • Budget estimation
    • Quality measurement
    • Waiver programs and Case Management
    For a complete slide presentation, please contact No World Borders [email_address] http://www.noworldborders.com
  • ICD-10 Example Impact Assessment Functional Areas with the Most Risk For a complete slide presentation, please contact No World Borders [email_address] http://www.noworldborders.com
  • Risk Mitigation: Clearly Identify Roles for Payor, Provider Work Teams for ICD-10 Risky thinking: “I need a good ICD-10 project manager….” Comment: “Yes, but there are other organizational competencies needed…” See http://slidesha.re/icd10orgstrat For a complete slide presentation, please contact No World Borders [email_address] http://www.noworldborders.com
  • Provider Specific Factors for ICD-10 (Excerpt from Assessment) For a complete slide presentation, please contact No World Borders [email_address] http://www.noworldborders.com
  • ICD-10 and Documentation Provide audit trail of assumptions Mitigate punitive regulatory impacts
    • NAIC Audit Rules, Sarbanes Oxley
      • Revenue impacts
      • Medical Loss Ratio
    • Selected areas for document trail
      • Board and management minutes
      • Risk assessment and documentation
      • Business continuity plan documentation
      • Back up procedures
      • Service provider contracts, SLAs
      • Testing plans
    http://www.noworldborders.com
  • What’s next? http://www.noworldborders.com
    • Discovery & Remediation Tools:
    • COBOL
    • .NET
    • Java
    • 9 to 10 Frameworks:
    • Vocabulary
    • Concepts
    • Consortiums
    • Testing:
    • Leverage 5010 / ICD-10
    • End to end
    For a complete slide presentation, please contact No World Borders [email_address] http://www.noworldborders.com
  • Bottom Line
    • ICD-10 is a major enterprise effort requiring best practice planning
    • Only one chance go get ICD-10 right with single compliance date of 10/1/2013
    • Some organizations believe they will be forced to take short cuts because there is a shortage of time and resources to do it 'right.’
    • Use BCP principles to mitigate risk
    http://www.noworldborders.com
  • Mike Arrigo Managing Partner, No World Borders [email_address] 949-335-5580 x1001 Recorded webinar on BCP and ICD-10 http://www. noworldborders.com http://www.noworldborders.com