Managing The Conversion To HIPAA 5010 No World Borders Webinar by Mike Arrigo


Published on

On Monday, November 30th at 1pm ET Mike Arrigo, CEO of No World Borders, Inc. presented at a health care industry panel on HIPAA, electronic data standards and some specifics around implementing the EDI standard HIPAA 5010.

"Moving from ICD-9 to ICD-10 coding is one of the toughest challenges facing the healthcare industry today, said Arrigo. "This webinar helps health plans prepare now by learning the key steps in transitioning to HIPAA 5010 standards," he continued.

A panel of industry experts will convene for a 90 minute webinar on one of the most important topics in health care IT: "Managing the Conversion to 5010 HIPAA."

Topics Mr. Arrigo will cover include 1) Organizational readiness 2) Process impacts, 3) Auditing of requirements, 4) Test plans, 5) Organizational impact, 6) Project planning.

The panel covered several topics together, including:

Pacing yourself for execution
Keeping scheduling and communication a priority
Maximizing returns
Changing your transaction and code sets
Budget vs. actual cost
Tracking tools
Recognizing the value in integration testing and piloting
Pilot programs and test runs: When, how, who, and more
Going live: Avoiding pitfalls through lessons learned
New opportunities created by 5010
ROI potential for 5010
Reducing risks


Scott C. Cox, Associate Director, Navigant Consulting, Inc.
Ed Hafner, Chief Technology Officer, Foresight Corporation
Mike Arrigo, Managing Partner, No World Borders, Inc.
Prasad Lokam, Chief Architect, Miracle Software Systems, Inc.
Lisa Miller, XEO Health
Rajiv Sabharwal, Chief Solutions Architect, Health and Life Sciences, Infosys

  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide
  • Business Process Management is a natural starting point for implementing your SOA strategy with an initial project and in doing so extend the value of your existing underlying infrastructure. By service enabling your infrastructure you are enabling applications and infrastructure to work in support of the business process, instead of the applications and systems limiting the flexibility of how you do business. BPM in general seeks to Automate , manage & optimize dynamic business processes spanning organizations, systems & applications to create REAL business value. So how does it do that... Companies are structured by vertical organizations that perform discrete functions, i.e. HR, Finance, Manufacturing, Sales and Marketing, etc. IT fields applications and systems in support of the discrete functions of these organizations, i.e., CRM, SFA, Human Capital Management, Manufacturing Execution Systems, Supply Chain Management, etc. IT also fields horizontal infrastructure such as e-mail, portal, EAI, LDAP, etc. The reality is, however, that our business process span across these silos of discrete functions, applications and systems. As we service our customers, manufacture products, and administer the business, we engage people and systems across the board to complete complex processes. (Feel free to elaborate more on the problem from your own experience or from your customers’). BPM abstracts from the underlying physicality of those systems a process model, as you see here. In this picture, the orange symbols represent human steps and activities while the blue represent system-level interactions. A human interaction is treated just as elegantly as a system level interaction. BPM systems take these process diagrams and turn them into executable process applications without imposing changes to the underlying systems giving the business what is often referred to Agility, the ability to rapidly change based on business conditions. Information is sent and received to the right system or person, at the right time and in the right context for them to accomplish the task or tasks that make up the overall process. The BPM System keeps track of the state of the overall process (long running processes too…) and audits every single interaction every step of the way. This enables full control of how processes are executed, provides irrefutable documentation for compliance requirements, and allows business and process owners to view the state of their processes through sophisticated dashboards. Agreement on standards such as XML, BPMN and others in the web services world now enable us to cost effectively implement these solutions in weeks not years. These new process applications work in support of how the business people want to operate as opposed to being forced to operate as the application requests them to. Process models are now “should be” states not “has to be” states.
  • Managing The Conversion To HIPAA 5010 No World Borders Webinar by Mike Arrigo

    1. 1. Managing the Conversion to HIPAA 5010 Webinar   November 30, 2009 1:00pm EST Mike Arrigo Managing Partner, CEO No World Borders, Inc. For more details, assessment info [email_address] (Please send from your payor or provider email domain address)
    2. 2. Topics <ul><li>Process impact </li></ul><ul><li>Organizational impact </li></ul><ul><li>Requirements audits </li></ul><ul><li>Testing </li></ul><ul><li>Planning </li></ul><ul><li>Organizational readiness </li></ul>
    3. 3. HIPAA 5010 Implementation Approach <ul><li>Business and IT Alignment – Business, technology, strategies, and resources must be aligned to achieve results.  </li></ul><ul><li>Best-Practices Measurement – Best practice methods, and frameworks such as CMM & ITIL </li></ul><ul><li>Process Change and Innovation –Working with people and helping them see a better way to work. </li></ul><ul><li>Manage Expectations, find quick wins </li></ul><ul><li>Help the team Visualize the process to improve buy-in </li></ul><ul><li>Change Management & Communication – Communicate and distribute critical business knowledge, share the “wins” via social media </li></ul>
    4. 4. HIPAA 5010 Process Impact
    5. 5. “ Forced” Benefits of 5010 More than a Means to An End : ICD-10 <ul><ul><li>Organizational coordination, “de-siloization” </li></ul></ul><ul><ul><li>Review of trading partner process, integration </li></ul></ul><ul><ul><ul><li>Acknowledgements </li></ul></ul></ul><ul><ul><ul><li>Regulatory impacts </li></ul></ul></ul><ul><ul><ul><li>Testing </li></ul></ul></ul><ul><ul><li>Early look for places that electronic claims “drop to paper” </li></ul></ul>
    6. 6. Impact of 5010 & ICD-10 on Process Customer Service Product Development Revenue Management Reimbursement Management Finance & Administration Care Management Network Management Risk Management Member Services New Benefits Design Enrollment Claims Accounting Disease & Case Management Provider Contracting Rating Provider Services Product Setup & Configuration Billing & Receivables Fraud Detection Human Resources Utilization Management Network Management Underwriting Employer Services Billing Reconciliation Medicare/ Medicaid Financial Extracts Disease Management Claims Repricing Actuarial Broker Services Care Management Population Management
    7. 7. Visualize Current & Future To Ensure Alignment, Value Claims Process Enterprise Infrastructure Services (Mainframe legacy, Portal, SOA, IDRS, LDAP, EAI, E-mail, IT Operations) Customer Service Product Dev Care Mgmt Revenue Mgmt Reimb Mgmt Finance SFA Prodict LMS Inv MGMT B2B product ERP. SCM productinfo. MES DB ERP CRM BPM models, simulates, executes, manages, monitors, & optimizes those Business Processes. Customer Service Product Development Care Management Revenue Mgmt Reimbursement Management Finance & HR SFA Product LMS Inv MGMT B2B Enterprise Infrastructure Services (Mainframe legacy, Portal, SOA, IDRS, LDAP, EAI, E-mail, IT Operations) product ERP SCM product MES DB ERP CRM Organizational Units Real-World Business Processes span organizations, systems, and applications. Product Offerings to Members Claims Management Customer Services Processes
    8. 8.
    9. 9. Example Process Simulation
    10. 10. Example Process Model Artifact
    11. 11. Where to Apply Process Models <ul><li>Ideal projects </li></ul><ul><ul><li>Exception Handling (systems handle some work, people must deal with exceptions) </li></ul></ul><ul><ul><li>Corporate re-structuring, turn arounds </li></ul></ul><ul><ul><li>Best Practices (Process Excellence, Compliance) </li></ul></ul><ul><ul><li>Entry Point for Claims Upgrade Engagements </li></ul></ul><ul><li>Significant Human Interaction </li></ul>
    12. 12. HIPAA 5010 Organizational Impact
    13. 13. Understanding Stakeholder Impacts <ul><li>Health Plan Staff </li></ul><ul><li>Providers </li></ul><ul><li>Employers </li></ul><ul><li>Members </li></ul><ul><li>Vendors </li></ul><ul><li>Regulatory Agencies </li></ul>
    14. 14. What is the IT Orientation & Approach to 5010? <ul><li>Enterprise approach </li></ul><ul><ul><li>Receiving </li></ul></ul><ul><ul><li>Archiving </li></ul></ul><ul><ul><li>Validating </li></ul></ul><ul><ul><li>Transforming </li></ul></ul><ul><ul><li>Routing </li></ul></ul><ul><li>Federated claims system (legacy) issues </li></ul><ul><ul><li>System type (custom built, vendor customized) </li></ul></ul><ul><ul><li>Age & architecture of system (mainframe, SOA…) </li></ul></ul>
    15. 15. HIPAA 5010 Requirement Audits
    16. 16. Audit Capabilities Check List: Regulatory Experience & Judgment <ul><li>Understand unique architecture and business organization </li></ul><ul><li>Perform review of business requirements & artifacts </li></ul><ul><li>Provide a detailed regulatory gap analysis between: </li></ul><ul><ul><li>HIPAA 5010 Final Rule and X12 Implementation Guides for HIPPA 5010 covered transactions and acknowledgements) </li></ul></ul><ul><ul><li>System (i.e., receiving, archiving, validating, transforming, processing and responding) </li></ul></ul><ul><li>Facilitate defining the steps to complete 5010 Functional Specifications </li></ul>
    17. 17. HIPAA Transactions Experience <ul><li>HIPAA Transactions Experience: </li></ul><ul><ul><li>820, 834, 835, 837 P, 837 I, 837 D, 270/271, 276/277 and 278 transactions and the 999, </li></ul></ul><ul><li>Acknowledgements </li></ul><ul><ul><li>TA1 </li></ul></ul><ul><ul><li>277CA </li></ul></ul>
    18. 18. Impact of HIPAA Title II, Subtitle F With Respect to 5010 EDI Standards <ul><li>Privacy & Security </li></ul><ul><ul><li>Transactions </li></ul></ul><ul><ul><li>Code sets </li></ul></ul><ul><ul><li>Identifiers </li></ul></ul><ul><li>Trading partner security & governance risk assessments </li></ul>
    19. 19. HIPAA 5010 Testing
    20. 20. Testing Will Be Critical . . .
    21. 21. System Inventory, Test & Transition Plan (Sample Artifact)
    22. 22. Detail Test Framework (Sample Artifact)
    23. 23. HIPAA 5010 Planning
    24. 24. Planning – Do Not Underestimate <ul><li>Dec. 31, 2010, payers and providers complete first level testing </li></ul><ul><li>Conduct internal testing throughout 2010 </li></ul><ul><li>Once you realize that Level Two testing must be completed by the end 2011, final compliance dates are not so far away </li></ul>
    25. 25. Planning: Identify Principles for Stakeholder Interaction <ul><li>Address 4010 to 5010 cutover issues </li></ul><ul><li>Review current applications, IT projects </li></ul><ul><li>Design approach </li></ul><ul><ul><li>Impacted systems </li></ul></ul><ul><ul><li>Vendors </li></ul></ul><ul><ul><li>Members </li></ul></ul><ul><ul><li>Providers </li></ul></ul><ul><li>Requirements development & audit </li></ul> For detail plan in 15 PowerPoint Slides, Contact us
    26. 26. HIPAA 5010 Organizational Readiness
    27. 27. Achieving 5010: Organization Perspective
    28. 28.
    29. 29. Organizational Readiness Checklist Overall Industry Expertise (1 of 2) <ul><li>Visibility with and involvement in industry groups that shape the standards and their adoption timeframes </li></ul><ul><li>Ensure a “vendor agnostic” approach (not only tools, software) </li></ul><ul><li>Experience with multiple Health Plans, specifically with HIPAA Transactions (Blue Exchange, ITS etc.) </li></ul><ul><li>Vendor claims system experience </li></ul><ul><li>Transaction Management systems </li></ul><ul><li>X12 Transactions and Acknowledgements expertise </li></ul><ul><li>Understand TR3 implementation guides </li></ul> For Bios & Detail Capabilities Contact Us
    30. 30. Organizational Readiness Checklist Overall Industry Expertise (2 of 2) <ul><li>HIPPA 4010a and HIPAA 5010 regulatory requirements expertise </li></ul><ul><li>WEDI experience (an industry standards organization for EDI transactions) </li></ul><ul><li>Understand WEDI/NCHICA 5010 implementation timeline </li></ul><ul><li>CMS, ICD-9 and ICD-10 experience to understand global “end game” ramifications </li></ul> For Bios & Detail Capabilities Contact Us
    31. 31. Most Payers & Providers Are Under Estimating the Joint Requirement & Analysis Time for 5010 and ICD-10 <ul><li>Establishing organizational structure </li></ul><ul><li>Planning to replace, upgrade your claims system </li></ul><ul><li>Secure compliance attestation from clearing houses </li></ul><ul><li>Review process impacts and improve process </li></ul><ul><li>Developing scoping and requirements documents </li></ul>
    32. 32. Market Intelligence <ul><li>Laggards </li></ul><ul><ul><li>Lack of business & IT alignment </li></ul></ul><ul><ul><li>CIO short term budget concerns </li></ul></ul><ul><ul><li>Just getting started in understanding the landscape of vendors and approaches </li></ul></ul><ul><li>Leaders: </li></ul><ul><ul><li>Working to beat deadlines </li></ul></ul><ul><ul><li>Investing heavily in process, people, systems </li></ul></ul><ul><ul><li>Challenged by legacy issues </li></ul></ul><ul><ul><li>Intent on outsourcing claims processes for laggards, at a profit </li></ul></ul>
    33. 33. Prediction Based on Experience <ul><li>Most large IT projects fail on the first attempt </li></ul><ul><li>Usually, the cause is lack of business & IT alignment </li></ul><ul><li>Difficult to balance day to day with innovating new business value via IT </li></ul><ul><li>Talent management plans are an after thought </li></ul><ul><li>Suggestion for 5010 success : Make an early investment in outside professional guidance on these and other issues identified </li></ul>
    34. 34. Mike Arrigo Managing Partner, CEO No World Borders, Inc. For more details, assessment info [email_address] (Please send from your payor or provider email domain address)