>Trend (medical expenses, risk adjusted rating) >Pay claims (benefit configuration) >Contract (provider agreements spelling out reimbursement) >Report (HEDIS, encounter reporting, quality management) >Make medical necessity determinations (utilization management) >Enroll members into case management >Prevent inappropriate payments (subrogation, fraud and abuse) >Better coordination of plan to plan COB payments >Transmission of claim re-pricer data >Encoded treatment detail will enable payers to compare costs >Reduce repeat counts for loops and segments and replace generic descriptions with specific descriptions >Properly leveraging ICD-10 can reduce medical loss ratios
Reduce repeat counts for loops and segments and replace generic descriptions with descriptions specific to the context. Properly leveraging ICD-10 can reduce medical loss ratios through keeping chronic diseases from progressing and providing treatment at the lowest cost setting.
Better coordination of plan to plan COB payments. Transmission of claim repricer data External cause of injury
Increased specificity in ICD-10 coding will enable payers to develop expertise in outcome reporting, analysis and pay for performance. The encoded treatment detail will enable payers to compare costs and results for treating specific illnesses using different modalities of care and to work with providers to improve outcomes. ICD-10 will make data easier to aggregate and push out to members. • More precise clinical documentation of members with chronic diseases will enhance the medical management capabilities of members. Chronic care has been the fastest growing segment in terms of member numbers and costs. Payers properly leveraging ICD-10 can reduce medical loss ratios through keeping chronic diseases from progressing and providing treatment at the lowest cost setting. • Because of the level of detail encoded in ICD-10, payers will be able to auto-adjudicate more claims by not having to request and refer to medical records that would otherwise be required to support a claim. Time delays and costs involved with obtaining missing information will be decreased.
Craig & Barry
If anyone hasn’t seen this timeline, come talk with us after…..
Trading Partners begin testing Jan 31, 2011 5010 Compliance Jan 1, 2012 ICD-10 Compliance Oct 31, 2013
Craig & Barry
Coordination of multiple in-house software system upgrades to compliant versions.
Assessment of remediation requirements for interfaces to in-house software systems without availability to compliant version specifications.
ICD-10-CM contains approximately 87,000 codes ICD-10-PCS contains approximately 68,000 codes. ICD-10-PCS was developed by CMS for use in US in-patient hospital settings only. The new ICD-10 system uses 7 alphanumeric digits while ICD-9- CM coding uses only 3 or 4 numeric digits. Because of ICD-PCS, the US implementation will be far more complex than it was for other countries. The chosen approach minimized implementation costs by using work-arounds and companion guides, but resulted in each payer having its own proprietary version of the standard. This practice has added both cost and complexity to the nation's healthcare system.
Craig & Barry
5010 Staging implementation. >Map 5010 to 4010 at the gateway or point of reception allowing all downstream systems to continue functioning normally. >Implement in-house system upgrades and remediate the database changes impact on down stream data paths (data warehouses, Operational Data Stores, Application software). These can be performed from the front end to the backend or from business backend to the frontend. Determine this by assessing which components of the path you would least like to remediate multiple times. Typically front to back end is chosen since claims processing usually exists in the front end and impacts data layouts the most. >Remediate 5010 from point of reception to backend one component at a time. This may require you to complete remediation of all components before implementing. Create 5010 versions of applications leaving the 4010 versions operational to facilitate parallel testing. >Perform parallel testing from point of reception to backend one component at a time. When the entire path has been tested Implement the 5010 remediation. >Implement small early adopters to facilitate functional testing and overall operational testing. Be sure to ask these trading partners to supply 4010 & 5010 so that you can fall back on 4010 if a production issue arises. Implement a single large early adopter. Chose this trading partner considering their ability to work through issues without jeopardizing the business relationship. (Request 4010 and 5010 formats for all transmissions). > Stage Implementations with completion dates being on or before 01/01/2012
Craig & Barry
Organizational Readiness Gap Analysis Organizational structure, business partners, past HIPAA experiences (governance, lessons learned), business change methods and experience, strategic plans, budgets, and ICD-10 knowledge Business Process Gap Analysis Identify business process gaps, risks, new capabilities required, and key business rule changes IT Systems Gap Analysis Identify required system and data changes, 5010 impacts, key vendor readiness, risk, and linkage of automation and business organization Cost Assessment Based on cost project factors High Level Roadmap for Compliance
Transition to Rob
Tailored solution and seamless integration 5010 compliant today Extensible platform Largest direct provider to payor network Award winning customer service
The Payor Connectivity Services (PCS) 5010 and Beyond Program was developed to ensure health plans comply with federal regulations including HIPAA 5010, ICD-10, and beyond.
The program combines RelayHealth’s proven PCS technology with complimentary implementation and advisory services, providing payers with a solution that is richer in functionality than a traditional EDI clearinghouse, but with the flexibility to scale with changing requirements.
HIPAA-compliant Intelligent Gateway Scalable Software as a Service (SaaS) platform Modular design which enables expansion of applications and functionality Payor-customizable pre-adjudication validation and routing Ability for submitters to correct claims prior to submission 4010-to-5010 conversion service 5010 testing tool ICD-9 to ICD-10 compliance Payor and provider web-based reporting
Rob -- ?
Maybe ask for show of hands after each….
Pragmatists (60%) will focus on basic compliance. This includes basic coding, EDI transactions implementation, updating of governmental reporting, and required core administrative and revenue cycle process updates. Many of these orgs will use wrap-around solutions such as EDI and code set cross-walks to minimize cost and impact on systems. Collaborators (20% to 25%) will look beyond basic compliance to include the remediation of internal reporting and implementation of advanced analytics and payment monitoring to leverage the detailed data obtained through ICD-10 coding. Mid-sized plans in this group are expected to collaborate to share the ICD-10 remediation cost. Innovators (15% to 20%) will seek to leverage HIPAA 5010/ICD-10 compliance to add strategic value to their organization through transforming HCM, contracting and business acquisition processes, deploying advanced training, and developing sophisticated outcome management and physician scorecards. These organizations will approach remediation as an opportunity to develop new business partnerships, define new business models and create new care procedures. Some organizations will attempt to opt out of ICD-10 remediation due to investment involved and others will seek to outsource remediation to third parties, either directly or by moving from in-house systems and processing to a BPO-based model.
ICD-10 Staging implementation. Develop/purchase a bidirectional Equivalency mapping - Used only when a valid equivalent code exists. Develop/purchase a crosswalk service. Keeping in mind how your may need to vary the outcome to accomodate differences in provider contracts and benefits plans. Develop new versions of all ICD dependent reports and analysis using the Equivalent or crosswalked ICD-10 codes. Compare the results to the ICD-9 versions and address differences through modification of crosswalk, contracting or benefit plan configuration. Develop ICD-10 versions of contract terms and benefit terms allowing adjudication to adjudicate historical run out claims using icd9 and new claims using icd10. In a test environment convert paid claims icd9 to icd10 and adjudicate. compare results and address.
Wedi fall 2010 hipaa5010
Impact Assessment & Readiness
WEDI Fall Conference - November 8-11, 2010
Are you riding the waves
or is there going to be a
• Rob Fisher, Director, Payer Services, RelayHealth
• Craig Penrose, PMP, Senior Director, Assessment,
Procurement and Consulting, FlexTech
• Barry Reeher, Senior Technical Consultant,
Did you know?
The transition to 5010 involves 5000 data element changes.
• How will 5010 make life better?
• Most common issues facing health plans
• Best implementation practices – 5010
• How is FlexTech helping health plans succeed with
• How is RelayHealth’s Payer Services helping payers
reach their compliance goals?
• With more precise clinical documentation, payers can reduce
medical loss ratios.
• Payers will be able to auto-adjudicate more claims.
• Prevent inappropriate payments (subrogation, fraud and abuse).
• Locating missing information will be easier, reducing time delays
• Replacing generic descriptions with specific descriptions
streamlines the process.
How will 5010 make life better?
The conversion to 5010 will make information exchange simpler and more
straightforward, improving all aspects of healthcare business, and driving
payers to improve business strategy.
5010 / ICD-10 Timeline
Where is your org in the readiness timeline?
• Many payers have multiple vendor and internally supported
systems and applications.
• Retain all inbound 5010 data for outbound processing
• Coordination of multiple software system upgrades to compliant
• Assessment of remediation requirements for interfaces to
software systems without compliant version specifications.
• Payers will likely have to support transactions in both formats for
a period of time as an accommodation.
Most common issues facing health plans
These conversion projects come at a time of extreme financial and
resource challenges. The transition carries direct financial risk
because it is related to billing and revenue management.
Best implementation practices – 5010
• Map 5010 to 4010 at the gateway.
• Implement system upgrades and remediate the database
• Remediate 5010 from point of reception to backend, one
component at a time.
• Perform parallel testing from point of reception to backend,
one component at a time.
• Implement small early adopters to facilitate functional testing
and overall operational testing.
• Implement a single (large) early adopter.
• Stage implementations with completion dates being on or
Best Practice – 5010 Project Deliverables
• Organizational Readiness Gap Analysis
• Organizational structure, business partners, past HIPAA
experiences (governance, lessons learned), business change
methods and experience, strategic plans, budgets, and ICD-10
• Business Process Gap Analysis
• Identify business process gaps, risks, new capabilities required,
and key business rule changes
• IT Systems Gap Analysis
• Identify required system and data changes, 5010 impacts, key
vendor readiness, risk, and linkage of automation and business
• Cost Assessment
• Based on cost project factors
• High Level Roadmap for Compliance
• Proven Methodology
• Proven Tools
• Repeatable & Predictable Results
• History of Experience
• Objectivity and Focus
• Bandwidth to Deliver
A Third Party Advantage
How is FlexTech helping health
plans succeed with their projects?
Why health plans turn to a third party resource
Assessment Methodology Work Streams
Data Gathering Data GatheringData Gathering
Assessment Area Tool Kits
• Assessment Work Plan Template
• Downstream impacts for data and business
• Existing and future projects
• Application Interview Functional Inventory
• Stakeholder Responsibilities Matrix
• 5010 Charter Template
• 5010 Scope Template
• 5010 Business Requirements Template
• Business Process Inventory
• Interface Inventory
• Data Flow Inventory
• Application Inventory Interview Crosswalk
• CMS Mapping of 4010A1 to 5010
• X12 and Changes Guides
• Vendor and Product Cross-Reference and Analysis Tool
• 5010 and ICD-10 Transaction Conceptual Views and Flow Guide
• Profile and Readiness Checklist
• Final Presentation and Written Report Templates
How is RelayHealth Payer Services
helping payers reach their compliance goals?
RelayHealth for our
5010 solution. Their
(PCS) provides much
more value than a
traditional EDI trans-
with the flexibility to
scale with our changing
- PCS Customer
PCS 5010 & Beyond Program
• HIPAA-compliant Intelligent Gateway
• Scalable Software as a Service (SaaS) platform
• Modular design which enables expansion of applications
• Payor-customizable pre-adjudication validation and routing
• Ability for submitters to correct claims prior to submission
• 4010-to-5010 conversion service
• 5010 testing tool
• ICD-9 to ICD-10 compliance
• Payor and provider self-service web reporting
• Complimentary implementation services
RelayHealth’s PCS 5010 and Beyond Program includes:
firstname.lastname@example.org / www.fasttrack5010.com
Preparing our customers to
think beyond 5010
Nine clients have contracted for PCS
implementation projects scheduled to
go live by December 2010.
“By choosing RelayHealth
PCS, complexity is reduced,
which will bring further
efficiencies to our processes,
and help to reduce costs. PCS
provides alternatives for how
we conduct transactions with
different partners and the
information we share.”
- PCS Customer
Payor Connectivity Services
With a modular design, PCS can be implemented so you can add future
functionality to scale with your changing requirements.
Payor Connectivity Services
5010 HIPAA Gateway
Built to handle health plan needs such as HIPAA 5010, clinical data transactions,
and pre-adjudication processing, PCS is an end-to-end solution that reduces the
gap between providers and payers.
• Support standard and
protocols as defined in
CORE Phase II
• RelayHealth translates
incoming data into any
format your systems
• Ability to split and route
files to you based on
PCS 5010 HIPAA Gateway
• Ensures transactions meet
• Flexibility to add health
plan specific business
• Rejects transactions based
on business rules
• Easily create companion
guides for your provider
community with the click of
PCS 5010 HIPAA Gateway
Reporting & analytics
• Visibility into reject
data and trends
• Grading of submitters
with common metrics
• Trading partner
• Channels problem
areas to management
• Audit reports
• Create alerts based on
5010 Certification Program
Education Data Generation
5010 - 4010
Trading Partner Testing
>What has your 5010 experience been?
>What’s your biggest concern?
• Rob Fisher
• Andy Fox
• Craig Penrose
• Barry Reeher
Contacts for Information
What’s your strategy?
• Pragmatists – Basic compliance. Basic coding, EDI transactions
implementation, updating of governmental reporting, and required core
administrative and revenue cycle process updates. Wrap-around solutions
such as EDI and code set cross-walks to minimize cost and impact.
• Collaborators – More than basic compliance. Remediation of internal
reporting and implementation of advanced analytics and payment
monitoring to leverage the data obtained through ICD-10 coding. Mid-sized
plans may collaborate to share the ICD-10 remediation cost.
• Innovators – Leverage HIPAA 5010/ICD-10 compliance. Focus on
strategic value through transforming HCM, contracting and business
acquisition processes, advanced training, and outcome management. These
orgs will see this as an opportunity to develop new business partnerships
and business models.
• Opt out of ICD-10 – Some orgs will try to avoid remediation but there is
no option to opt out.
Best implementation practices – ICD-10
• Develop/purchase a bi-directional Equivalency mapping.
• Used only when a valid equivalent code exists
• Develop/purchase a crosswalk service.
• Note that you may need to vary the outcome to accommodate
differences in provider contracts and benefits plans
• Develop new versions of all ICD dependent reports and
analysis using the Equivalent or crosswalked ICD-10 codes.
• Compare the results to the ICD-9 versions and address
differences through modification of crosswalk, contracting or
benefit plan configuration.
• Develop ICD-10 versions of contract terms and benefit terms
allowing adjudication to adjudicate historical run out claims
using ICD-9 and new claims using ICD-10.
• In a test environment convert paid claims ICD-9 to ICD-10
and adjudicate. compare results and address.23