ICD-10 Preparation


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ICD-10 Preparation

  1. 1. Preparing for ICD-10 12/2/2009
  2. 2. Facts • ICD-9 Diagnosis Codes • ICD-10 Diagnosis Codes > 13,000 diagnosis codes > 68,000 diagnosis codes > Uses 3- to 5-digit codes > Uses 3- to 7-digit codes > Chapters 1-17 are numeric > Digit 1 is alpha (A-Z, not • Supplemental chapters case sensitive) use an alpha first digit (E > Digits 2 and 3 are numeric or V) > Digits 4-7 are alpha or numeric © Ingenix, Inc. 2
  3. 3. Facts • ICD-9 Procedure Codes • ICD-10 PCS Codes > 11,000 procedure codes > 87,000 procedure codes > Uses 3- to 4-digit codes > Uses 7-digit codes > All four digits are numeric > Any of the digits can be alpha or numeric © Ingenix, Inc. 3
  4. 4. ICD-10 Challenges for Hospitals • Increase in reporting requirements • Update older technology systems • Evaluate new value-based purchasing initiatives • Increase budgets for investment in EHR applications • Incorporate computer-assisted coding in documentation process • Improve clinical documentation to support higher level of specificity • Provide incentives for coders to stay and learn new coding system • Prepare for loss in productivity due to coding backlogs • Train clinical and non-clinical staff • Prepare for reduced cash flow due to provider and payer processing errors © Ingenix, Inc. 4
  5. 5. ICD-10 Challenges for Hospitals • Do it yourself or outsource? > Do you have the: • Staffing resources to prepare and maintain productivity? • Expertise to conduct needs and gap analyses? • Expertise for implementation and training? • Budget to cover one-time costs vs. recurring costs? • One-time: training, system modifications, etc. • Recurring: employee salaries © Ingenix, Inc. 5
  6. 6. ICD-10 Challenges for Hospitals • Evaluate Vendors > Work with your vendors to determine if system modifications or upgrades are available > Ask vendors: • What is the status of their solutions for becoming ICD-10 or 5010 compliant? • Have their systems been tested? • Will their systems accept the ICD-10 code set in 10/2013? • Have their systems 5010 transmissions been tested for compliance? • What is the availability schedule for compliant solutions? • What is the upgrade schedule for solutions that will not be ready by the implementation data? © Ingenix, Inc. 6
  7. 7. Accelerated Vendor Section Selecting a vendor, product or tool – what could be easier right?  I know my requirements so  let’s just bring in a few vendors for a demonstration – what could go wrong…. We offer a highly customizable and accelerated vendor selection methodology that will help  you select the right solution for your business model and unique needs © Ingenix, Inc. 7
  8. 8. ICD-10 Challenges for Hospitals • Budgeting > RAND Corporation and Robert E. Nolan Company attempted to quantify industry costs resulting from the adoption of ICD-10 > Figures vary widely: • $6B - $14B (Robert E. Nolan Company) • $1.15B (RAND Corporation) > MGMA estimated the average 10-physician practice group would spend $285,000 to transition to ICD-10 > Figures not too helpful for organization to use to set budgets; HHS provides framework that organizations can use to estimate one-time and on-going costs © Ingenix, Inc. 8
  9. 9. ICD-10 Challenges for Physicians • Replace or update existing practice management billing system software • Train clinical and administrative staff on new code sets and changes to technology • Modify current practice work flow • Review, amend or replace vendor, clearinghouse and health plan contracts and data requirements • Update superbills and corresponding mapping strategies • Improve quality and accuracy of clinical documentation practices • Revise or replace billing forms © Ingenix, Inc. 9
  10. 10. Start Preparations Now • Most far-reaching change in U.S. health care to date • Impacts reimbursement, marketing and research • Assess strengths, weaknesses and limitations sooner rather than later © Ingenix, Inc. 10
  11. 11. Hospital and Physician Solutions 12/2/2009
  12. 12. Understanding the Industry Forces & Trends in the Provider Market We have an extensive understanding of the market forces and trends and the resulting business challenges and opportunities facing hospitals, health systems and physician groups. – Payment models changing through consumerism and the move to severity adjusted reimbursement – Patient safety – Measuring and improving quality – National attention and competitive pressures to implement EMR capabilities – Emerging care models to reduce cost – Election year and looming policy reform – Staffing shortages – Census drivers – Aging population and more chronic care – Modernization and interoperability © Ingenix, Inc. 12
  13. 13. Delivering Solutions for These Business Challenges Our consulting solutions can help you improve patient safety and health quality outcomes, find operational cost efficiencies, ensure equitable payment for services and comply with regulatory guidelines. – Strategic Planning – IT Strategy, System Implementation & Information Optimization Mgmt. – Enterprise Information Management & Data Operations Mgmt. Clinical Mgmt. Our Warehousing Clients Revenue Financial – Clinical & Consumer Engagement Mgmt. Strategy & Mgmt. Program – Revenue Cycle Optimization Optimization – Financial Advisory – Health Care Reform & Government Regulation Our interdisciplinary consultant teams bring together market-leading capabilities to help hospitals, health systems and physician practices achieve their business objectives. © Ingenix, Inc. 13
  14. 14. Strategic Planning Solutions Set corporate vision and your organization’s strategic agenda by evaluating the newest research, understanding the emerging medical technology trends and learning how hospitals and physician groups across the country and throughout the world are treating patients like yours and setting their business strategy and service line mix. Services include: – business strategy evaluation and development – organizational governance © Ingenix, Inc. 14
  15. 15. IT Strategy, System Implementation & Optimization Solutions Transform your processes, your systems and your business to achieve safety and efficiency. Services include: – IT assessments, strategy and governance – vendor evaluation and system selection – clinical system implementation – process reengineering and system optimization – system integration – training and curriculum development – testing and environments management © Ingenix, Inc. 15
  16. 16. Enterprise Information Mgmt. / Data Warehousing Solutions Utilize multi-system hospital data along with industry benchmarks and payer data to measure and improve financial and clinical performance. Services include: – payer / hospital claims analytics – payer connectivity – enterprise information management and data warehousing – data integration and decision support © Ingenix, Inc. 16
  17. 17. Data Warehousing and Information Management Data is everywhere – but how can you make smart business decisions unless the data is  transformed into useful information which is managed, integrated and available?  We can help… © Ingenix, Inc. 17
  18. 18. Clinical & Consumer Engagement Solutions Leverage information and technology to enhance patient safety, improve physician relations and adherence to evidence-based medicine guidelines, engage patients, optimize clinical efficiency and contract with managed care. Services include: – evidence-based medicine / pay-for-performance analysis – physician connectivity and engagement – consumer connectivity and engagement – quality assessments and never-event audits © Ingenix, Inc. 18
  19. 19. Revenue Cycle Optimization Solutions Drive operational cost efficiencies by improving revenue cycle management, reimbursement and business process redesign. Services include: – coding and billing compliance – ICD-10 transition preparedness – revenue cycle optimization – operating performance benchmarking and optimization © Ingenix, Inc. 19
  20. 20. Business Advisory and Actuarial Services Utilize information effectively to set financial strategy, manage department and service line profitability, manage operational costs, increase net revenue realization, define growth opportunities and comply with regulations. Services include: – financial strategy – benchmarking and actuarial modeling – capacity planning – managed care contracting strategy development – debt capacity analysis and financial projections – enterprise-wide strategic plan and service line plan development – community-based safety net strategy development and financing options © Ingenix, Inc. 20
  21. 21. Health Care Reform & Government Compliance Solutions Understand the impact of health care reform on providers and alternative strategies for dealing with the continued challenge of cost pressures for publicly-financed and uninsured populations. Services include: – financial and economic analysis of regulatory proposals – government program payment adequacy/shortfall analysis – recovery audit contractors (RAC) education, mock and shadow audits, appeals support and analytic reports © Ingenix, Inc. 21
  22. 22. Payer Solutions 12/2/2009
  23. 23. Operations Assessment and Optimization What is it? • In today’s environment, businesses are more challenged than ever to achieve optimal  quality and efficiency in their administrative operations. Case installation turnaround time is  often lengthy and error‐prone and can lead to missed employer commitments. Eligibility and  enrollment solutions are often inefficient. Claim processing quality issues may increase  turnaround times, manual rework, and operational costs, while lowering quality scores in  the public forum.  • Ingenix Consulting’s Operations Assessment service offerings focus on optimizing payer  administrative operations to drive cost savings, more effectively manage staffing, and allow  for scalability and growth. • Our methodology is designed to comprehensively identify and define current state people,  process and technology challenges, identify root cause drivers, develop short‐ and long‐term  future state models, and implement solutions that improve the quality, efficiency, and  timeliness of a payer’s business operations. © Ingenix, Inc. 23
  24. 24. Operations Assessment and Optimization Our Experience and Expertise © Ingenix, Inc. 24
  25. 25. Operations Assessment and Optimization An Integrated Service Offering Cont’d •The operations assessment & optimization service offering helps clients reduce operating costs,  prepare for future growth, and ensure proactive compliance with current and future regulations •This powerful offering can be sold as a standalone to clients or embedded as a “phase II” in numerous  other Ingenix Consulting offerings HCOT IBS HSO GPO FA IOD Operations  Stepwise Claims payment  Medical trend  Executive  MA strategy strategy Medpoint IT accuracy issues analysis dashboard Scalability, cost/  Underwriting  Claims operations  Operation strategy  Service & claims  End‐to‐end  headcount & defects ops issues issues for growth ops issues operating issues Operations Assessment INVESTIGATE INNOVATE IMPLEMENT IMPROVE OPERATE • End‐to‐end or targeted  • People, process, and  • Detailed delivery  • Monitor processes and track  • Operations and Ongoing  operations assessment technology short and long‐ requirements  metrics post deployment Management • Identification of people,  term recommendations • Delivery of people, process,  • Iterative improvement  process, and technology  • Comprehensive  and technology  process deployment and  issues workstream workplan  requirements and design assessment development Cost:  $50‐75K Cost:  $250‐500K Cost:  $250‐500 Cost:  $150‐300 Cost:  $50‐75K MEASURE & ITERATE Powerful Results Scalability for  Cost and headcount  Increased operational  Additional Ingenix  Defect reduction growth reduction efficiency products and services © Ingenix, Inc. 25
  26. 26. Operations Assessment and Optimization Real Example, Real Results Situation: Our client was a Medicare/Medicaid payer that had identified three challenges: They were concerned they would not be prepared for an upcoming Medicare audit They did not have a handle on whether the staffing levels in their claims operations were  appropriate They did not have confidence that their TPA was correctly paying their claims What Ingenix Consulting Did: Ingenix Consulting combined our operations assessment offering with GPO & HSO capabilities to conduct: A CMS Part C Mock Compliance Audit to identify compliance gaps A Claims Operations Assessment to identify process and technology gaps & assess staffing levels A Medicare Claims Payment Accuracy Review to determine how accurately the TPA was paying  claims Results: Within 5‐6 weeks Ingenix Consulting delivered the following: Identified and corrected compliance gaps that would have led to fines Identified process changes that will create IRR of 115% and NPV of $300K through headcount  reduction Identified $1M in claims overpayments against $16M in total payments IC is now working with the client to structure a Phase II engagement to help execute on the findings of the operations  © Ingenix, Inc. 26 assessment
  27. 27. Ingenix Consulting Real Example, Real Results “Ingenix Consulting was able to combine the services of it’s Business Advisory and Actuarial  Services practice and the Health Care Operations and Technology services to provide  solutions for our Medicare/Medicaid payer client.  The client needed to understand the  impact of changing contracts to reflect state specific Outpatient Prospective Payment  System Methodology.” • IC was able to evaluate the financial impact of contracting changes on actual plan  specific data. • IC identified providers which contracting changes would be significant and need  additional communication. • IC prepared a list of existing data deficiencies in need of attention prior to the transfer  of methodologies. • IC was able to update 2010 budget estimates to reflect the savings to be achieved with  updated contracting. © Ingenix, Inc. 27