Icd 10 and icd10 medical policy health plan under hipaa

1. Health Plan ICD-‐10 Medical Management ICD-‐10 Medical Policy Remedia�on Improvement Opportuni�es

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. 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. 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. 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. 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. 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. 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. 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. 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. 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

Icd 10 and icd10 medical policy health plan under hipaa

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