Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Icd 10 and icd10 medical policy health plan under hipaa

1,783 views

Published on

ICD-10 creates challenges for health plans who want to transition successfully from ICD-9 with respect to defining and redefining medical policy. This presentation addresses best practice approaches.

  • Login to see the comments

Icd 10 and icd10 medical policy health plan under hipaa

  1. 1. Health  Plan   ICD-­‐10  Medical  Management     ICD-­‐10  Medical  Policy  Remedia�on   Improvement  Opportuni�es  
  2. 2. ICD-­‐10  and  Medical  Policy  Management   1.  Guiding  principals  for  Care  Management   Improve  wellness,  cost  savings,  auto-­‐adjudica�on,  etc.   –  ICD-­‐10  specificity  will  allow  rules  to  enhance  pre-­‐auth  and  auto-­‐ adjudica�on,  improve  accuracy  and  consistency  applying  policies   2.  ICD-­‐10  Educa�on  and  Awareness   3.  Develop  Criteria  for  priori�za�on  of  Policies  to  remediate   –  Base  on  precise  intent  and  services   4.  Clearly  define  intent  of  policy  (codable)   –  Requires  increased  $,  �me  for  policy  reviews,  expedited  approval   –  lack  of  staff  could  slow  process   5.  Configure  Claims  System  to  reflect  intent   6.  Tes�ng  adjudica�on  results   –  Mul�ple  scenarios  with  each  policy   7.  Maintenance  of  Configura�ons  &  Rules   –  Classify  each  code  as  Include,  exclude,  review   For  a  complete  copy  of  this  material  please   contact  ICD10@noworldborders.com     Note:  Material  developed  in  partnership  with  Health  Data  Consul�ng     h�p://www.healthdataconsul�ng.com  
  3. 3. Measures  of  Success     Compare  adjudica�on  rates  pre  and  post  policy   implementa�on     Reduc�on  of  manual  pre-­‐authoriza�on     Increased  %  of  �me  allocated  to  case   management     Poten�al  Nega�ve  –  Increased  Medical  Loss   Ra�o   For  a  complete  copy  of  this  material  please   contact  ICD10@noworldborders.com     Note:  Material  developed  in  partnership  with  Health  Data  Consul�ng     h�p://www.healthdataconsul�ng.com  
  4. 4. Tools  &  Resources     Research & evaluate tools to manage policies   Resource for standard clinical policies –  Compare to existing policy templates: Aetna, Harvard Pilgrim, etc. policies are available   Implement Policy à ICD-10 code reference tool –  Classify each code as Include, exclude, review   Chose policies that are best to implement –  Top 10, easy to implement and manage –  Frequently used   Potential - Outsource for development of policy   Develop Guide or Manual for Policy development. For  a  complete  copy  of  this  material  please   contact  ICD10@noworldborders.com     Note:  Material  developed  in  partnership  with  Health  Data  Consul�ng     h�p://www.healthdataconsul�ng.com  
  5. 5. 1.  Guiding  Principles     Determine  Guiding  Principals   (per  Health  Plan  State  law)   –  Efficient, Economical delivery of healthcare (title 49, Ch. 20 Utah code) –  Mission – Trust vs. Competitive payer –  Balanced policy to deliver both appropriate care and cost effective care –  Address both Clinical, Payment and Operational policy in ICD-10 Benefit:   1)  Incremental  –  Perm.   2)  Clarity,  speeds  policy   development  process   3)  Reduce  conflict,   reduce  re-­‐work   Measure:   1)  Did  we  complete?   For  a  complete  copy  of  this  material  please   contact  ICD10@noworldborders.com     Note:  Material  developed  in  partnership  with  Health  Data  Consul�ng     h�p://www.healthdataconsul�ng.com  
  6. 6. 2.  ICD-­‐10  Educa�on  /  Awareness   Deeper  understanding  of  code  set  and  structure     Role  based  ICD-­‐10  Training   –  Clinicians,  Dra�er  of  Policy,  Configurators,  Approvers,  Case  Managers,   decision  makers   –  Claims  Adjusters,  Customer  Service,  IT     Intro  /  Overview     Terminology  differences  ICD-­‐9  to  ICD-­‐10     Coding     For  a  complete  copy  of  this  material  please   contact  ICD10@noworldborders.com     Note:  Material  developed  in  partnership  with  Health  Data  Consul�ng     h�p://www.healthdataconsul�ng.com  
  7. 7. 3.  Policy  Priori�za�on  Criteria       Criteria  for  Priori�za�on  of  Policies   –  High  dollar  (high  value)  cases   –  High  volume   –  Opportunity  for  automa�on  or   streamlining  process   –  High  margins  for  providers   –  Improve  downstream  processes   –  Improve  outcomes  for  pa�ents   –  Exis�ng  ICD-­‐9  legacy  policies     Build  Inventory  of  exis�ng  policies   –  100  Opera�onal  policies   –  400  Clinical  policies     Build  Inventory  of  New  Policies  (ICD-­‐10)   –  Analysis  of  exis�ng  claims  u�liza�on     Apply  Criteria  for  priori�za�on   Benefit:   1)  Binary  -­‐  Temp   2)  Focus   3)  Scope   4)  U�lize  resources   �mely   Measure:   1)  Is  it  done  or  not?   2)  Did  criteria  reduce   scope  for  remedia�on   3)  Did  we  apply  criteria   to  Inventory?     For  a  complete  copy  of  this  material  please   contact  ICD10@noworldborders.com     Note:  Material  developed  in  partnership  with  Health  Data  Consul�ng     h�p://www.healthdataconsul�ng.com  
  8. 8. 4.  Clearly  Define  Intent  of  Policy     Iden�fy  owner  responsible  for  dra�ing   policy     Define  policy  components  and  iden�fy   whether  clinical  or  payment/  opera�onal   –  Include  Venn  diagram  to  show  shared   components   –  Confirm  policy  format   –  Clinical  valida�on  of  applicability   –  Coding  Analyst,  tes�ng  of  configurability   –  Coordinate  linked  policies  (clinical  &   opera�onal)   –  Policy  dic�onary,  consistent  terminology   (reusable  across  policies)     Policy  governance  /  approval     Develop  best  prac�ces  for  policy  wri�ng     Benefit:   1)  Incremental   downstream   2)  Permanent   3)  Reduced  �me  to   make  policies   Measure:   1)  How  long  does  this   step  take?  (per   policy)   2)  Track  Pre  vs.  Post     For  a  complete  copy  of  this  material  please   contact  ICD10@noworldborders.com     Note:  Material  developed  in  partnership  with  Health  Data  Consul�ng     h�p://www.healthdataconsul�ng.com  
  9. 9. 5.  Configure  policy  to  reflect  Intent     Must  link  from  Policy  to  codes   – ICD-­‐10  Diagnosis   – ICD-­‐10  Procedure,  CPT,  HCPC     System  Configurator  training     Need  way  to  define  codes  in   System   – Services  in  ICD-­‐10   – Procedures  in  ICD-­‐10   Benefit:   1)  Enable  use  of   policy   Measure:   1)  Time/  resources   per  policy   2)  Level  of  re-­‐work   required     For  a  complete  copy  of  this  material  please   contact  ICD10@noworldborders.com     Note:  Material  developed  in  partnership  with  Health  Data  Consul�ng     h�p://www.healthdataconsul�ng.com  
  10. 10. 6.  Tes�ng     Create  scenarios  test  intent   of  policy  under  ICD-­‐10   – Owner  of  test  case   development   – Internal  test  cases   – External  test  cases   – Clinical  /  pre-­‐authoriza�on   – Claims  payment     End-­‐to-­‐end  tes�ng   Benefit:   1)  Avoid  business   disrup�on   2)  Avoid  unintended   consequences   Measure:   1)  Did  it  work?   2)  Actual  match   expected?     For  a  complete  copy  of  this  material  please   contact  ICD10@noworldborders.com     Note:  Material  developed  in  partnership  with  Health  Data  Consul�ng     h�p://www.healthdataconsul�ng.com  
  11. 11. 7.  Policy  Maintenance     Policy  documents     Table  storing  Policy  link  to  ICD-­‐10  codes   – Classify  each  code  as  Include,  exclude,  review     Standard  ICD-­‐10  code  tables     System  Configura�ons  &  Rules   For  a  complete  copy  of  this  material  please   contact  ICD10@noworldborders.com     Note:  Material  developed  in  partnership  with  Health  Data  Consul�ng     h�p://www.healthdataconsul�ng.com  

×