HIPAA 5010
Impact Assessment & Readiness
WEDI Fall Conference - November 8-11, 2010
Are you riding the waves
or is there g...
Speakers
• Rob Fisher, Director, Payer Services, RelayHealth
• Craig Penrose, PMP, Senior Director, Assessment,
Procuremen...
Agenda
• How will 5010 make life better?
• Most common issues facing health plans
regarding 5010
• Best implementation pra...
• With more precise clinical documentation, payers can reduce
medical loss ratios.
• Payers will be able to auto-adjudicat...
5010 / ICD-10 Timeline
5
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 o...
Best implementation practices – 5010
• Map 5010 to 4010 at the gateway.
• Implement system upgrades and remediate the data...
Best Practice – 5010 Project Deliverables
• Organizational Readiness Gap Analysis
• Organizational structure, business par...
9
• Proven Methodology
• Proven Tools
• Repeatable & Predictable Results
• History of Experience
• Objectivity and Focus
•...
Assessment Methodology
10
Assessment Methodology Work Streams
Organizational
Readiness
Business
Process Impact
IT Systems
...
Assessment Area Tool Kits
Overall Impact
Assessment
Management
• Assessment Work Plan Template
• Downstream impacts for da...
12
How is RelayHealth Payer Services
helping payers reach their compliance goals?
“We selected
RelayHealth for our
5010 so...
13
PCS 5010 & Beyond Program
• HIPAA-compliant Intelligent Gateway
• Scalable Software as a Service (SaaS) platform
• Modu...
Preparing our customers to
think beyond 5010
14
Nine clients have contracted for PCS
implementation projects scheduled to
...
Payor Connectivity Services
15
With a modular design, PCS can be implemented so you can add future
functionality to scale ...
Payor Connectivity Services
5010 HIPAA Gateway
16
Built to handle health plan needs such as HIPAA 5010, clinical data tran...
PCS 5010 HIPAA Gateway
EDI validation
17
• Ensures transactions meet
HIPAA requirements
• Flexibility to add health
plan s...
PCS 5010 HIPAA Gateway
Reporting & analytics
18
• Visibility into reject
data and trends
• Grading of submitters
with comm...
19
5010 Certification Program
Education Data Generation
For You
For Your
Trading
Partners
Migration Solution
5010 - 4010
C...
Questions?
20
>What has your 5010 experience been?
>What’s your biggest concern?
>What’s next?
• Rob Fisher
Rob.Fisher@RelayHealth.com
(770) 237-7719
• Andy Fox
Andrew.Fox@RelayHealth.com
(610) 430-3690
• Craig Penros...
What’s your strategy?
• Pragmatists – Basic compliance. Basic coding, EDI transactions
implementation, updating of governm...
Best implementation practices – ICD-10
• Develop/purchase a bi-directional Equivalency mapping.
• Used only when a valid e...
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Wedi fall 2010 hipaa5010

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  • Rob
  • Rob introduce
  • Rob
    Agenda – Hand off to Craig
  • Craig & Barry

    >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

    1. 1. HIPAA 5010 Impact Assessment & Readiness WEDI Fall Conference - November 8-11, 2010 Are you riding the waves or is there going to be a wipeout?
    2. 2. Speakers • Rob Fisher, Director, Payer Services, RelayHealth • Craig Penrose, PMP, Senior Director, Assessment, Procurement and Consulting, FlexTech • Barry Reeher, Senior Technical Consultant, FlexTech 2 Did you know? The transition to 5010 involves 5000 data element changes.
    3. 3. Agenda • How will 5010 make life better? • Most common issues facing health plans regarding 5010 • Best implementation practices – 5010 • How is FlexTech helping health plans succeed with their projects? • How is RelayHealth’s Payer Services helping payers reach their compliance goals? 3
    4. 4. • 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 and costs. • Replacing generic descriptions with specific descriptions streamlines the process. 4 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.
    5. 5. 5010 / ICD-10 Timeline 5 Where is your org in the readiness timeline?
    6. 6. • Many payers have multiple vendor and internally supported systems and applications. • Retain all inbound 5010 data for outbound processing (backfilling). • Coordination of multiple software system upgrades to compliant versions. • 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. 6 Most common issues facing health plans regarding 5010 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.
    7. 7. Best implementation practices – 5010 • Map 5010 to 4010 at the gateway. • Implement system upgrades and remediate the database changes. • 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 before 01/01/2012. 7
    8. 8. 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 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 8
    9. 9. 9 • 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
    10. 10. Assessment Methodology 10 Assessment Methodology Work Streams Organizational Readiness Business Process Impact IT Systems Impact Data Gathering Data GatheringData Gathering Evaluation Gap Analysis Evaluation Gap Analysis Evaluation Gap Analysis Recommendations/Roadmap Assessment Management Phases
    11. 11. Assessment Area Tool Kits Overall Impact Assessment Management • Assessment Work Plan Template • Downstream impacts for data and business • Existing and future projects Data Gathering Phase • 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 Evaluation Gap Analysis Phase • 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 Recommendations/ Roadmap Phase • Profile and Readiness Checklist • Final Presentation and Written Report Templates Assessment Toolkit
    12. 12. 12 How is RelayHealth Payer Services helping payers reach their compliance goals? “We selected RelayHealth for our 5010 solution. Their innovative Payor Connectivity Services (PCS) provides much more value than a traditional EDI trans- action clearinghouse with the flexibility to scale with our changing requirements.” - PCS Customer
    13. 13. 13 PCS 5010 & Beyond Program • 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 self-service web reporting • Complimentary implementation services RelayHealth’s PCS 5010 and Beyond Program includes: fasttrack5010@relayhealth.com / www.fasttrack5010.com
    14. 14. Preparing our customers to think beyond 5010 14 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
    15. 15. Payor Connectivity Services 15 With a modular design, PCS can be implemented so you can add future functionality to scale with your changing requirements.
    16. 16. Payor Connectivity Services 5010 HIPAA Gateway 16 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 advanced communication protocols as defined in CORE Phase II • RelayHealth translates incoming data into any format your systems require • Ability to split and route files to you based on various criteria
    17. 17. PCS 5010 HIPAA Gateway EDI validation 17 • Ensures transactions meet HIPAA requirements • Flexibility to add health plan specific business rules • Rejects transactions based on business rules • Easily create companion guides for your provider community with the click of a button
    18. 18. PCS 5010 HIPAA Gateway Reporting & analytics 18 • Visibility into reject data and trends • Grading of submitters with common metrics • Trading partner reports • Channels problem areas to management • Audit reports • Create alerts based on triggered events
    19. 19. 19 5010 Certification Program Education Data Generation For You For Your Trading Partners Migration Solution 5010 - 4010 Conversion Utilities 5010 Test Environment 5010 Certification Trading Partner Testing Program www.fasttrack5010.com www.testtrack5010.com
    20. 20. Questions? 20 >What has your 5010 experience been? >What’s your biggest concern? >What’s next?
    21. 21. • Rob Fisher Rob.Fisher@RelayHealth.com (770) 237-7719 • Andy Fox Andrew.Fox@RelayHealth.com (610) 430-3690 • Craig Penrose cpenrose@FlexTech.com 734-424-6898 • Barry Reeher breeher@FlexTech.com 21 Contacts for Information www.FastTrack5010.com www.FlexTech.com
    22. 22. 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. 22
    23. 23. 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

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