Icd 10 and icd10 medical policy health plan under hipaa

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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.

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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  

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