HIPAA 4010 a1 to 5010 migration


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  • Today I want to begin by reviewing some of the challenges facing organizations in addition to their 4010 to 5010 Migration.Next I want to examine the choices for a migration solution.I want to zero in on what Perficient believes is a rapid implementation solution called “Step Up/Step Down” from our partner Edifecs.We will demonstrate how this solution addresses the challengesI plan to review the Pros and Cons of this solution based on Perficient’s practical experience and then discuss Next Steps.
  • In this slide, we see a representation of the recommended tasks and timelines for 5010 and ICD-10 implementation and migration.In the line at the top of the graphic, we see the dates that CMS has specified for Level One and Level Two compliance, which CMS has defined and follows:Level One compliance is completion of all internal development and testing, with a milestone date of December 31, 2010Level Two compliance is completion of end to end testing with all trading partners, and is scheduled to be completed by December 31, 2011 – the day before the mandatory compliance date of January 1, 2012.In the graphic, we also see the different stages of Implementation, as well as a representation of the span of time for those activities – From Strategy & Assessment, to Design & Build, to Internal and External testing, conversion, and the ongoing training and outreach that will have to happen as we migrate to 5010. As you can see, time is short and deadlines are looming.One key item that is often overlooked is the external testing and performance testing to ensure that service level agreements with your trading partners are met.
  • ChallengesWe just looked at the timeline for an understanding of the regulatory deadline pressures. Here are a few other challenges facing organizations with a 4010 to 5010 migration:Completing large IT projects – most of our large provider organizations, especially hospitals, are working to implement electronic medical records systems. In healthcare payers, we are seeing claims processing systems being modernized and streamlined to reduce paperwork as well.Here is a big issue: The lack of experienced professionals with EDI X12 experience. Not only is there a shortage of people, but the rules and standards are being updated faster than tax software! Here is the issue that our video highlighted: Making sure that your 4010A1 and new 5010 transactions match for billing and accounts receivable. Your CFO isn’t going to want to hear that after the migration that the billing has suddenly increased or, worse yet, decreased. It will be critical to choose a solution that allows the management of this important issue. Otherwise there is a serious audit risk from government agencies and external organizations.We hear this one a lot. We are waiting on our healthcare application software vendor for ICD-10 upgrades, but we think their timeline will make us miss our regulatory deadlines! In addition, an upgrade to a major application (think EPIC or Cerner) will kick off extensive integration and regression testing in our organization. We need some options . . .
  • Let’s examine our options:Step Up / Step Down: This strategy implies making changes to the intake system of transactions (Gateway component) such that the inbound transactions are mapped or transformed from the 5010 transaction set to the 4010A1 transaction set and then passed downstream leaving the complete processing engine intact. In addition, outbound transactions are converted back to 5010 before being sent to trading partners. This strategy would limit the scope and the remediation effort as the transactionsbeing processed would continue unchanged.Remediation: This strategy implies making enhancements to core processing (or back-end) systems to meet HIPAA 5010 and ICD-10 compliance while at the same time upgrading the front-end systems (such as Gateway) in order to process 5010 transactionsand ICD-10 code sets.Complete replacement of systems: This strategy originates from the belief that the 5010 and ICD-10 changes are significant enough to require complete replacement of the entire claims processing system for the health plan. This would include the adjudication (claims processing) systems, transaction processing systems (EDI Gateway), user interfaces, reporting systems andpotentially other business systems.
  • Perficient has a dedicated Healthcare practice with subject matter expertise and practical hands-on knowledge of the business processes and HL7 transactions. We believe that a strong Toolset like the Edifecs Step Up/Step Down solution will be a real time-saver and can address testing which can extend an implementation. Most importantly, a tailored approach specific to your organization is a real time-saver. Combining the tailored approach and best practices will help you catch up to the looming deadlines.
  • The Edifecs5010 Solution consists of 3 elements – First, Our Edifecs5010 Step Up/ Step Down Solution that has a range of options – from a simple “translation” solution with pre-built maps for 5010 to 4010A1 and 4010A1 to 5010 conversion, to an “enterprise” version that incorporates more robust capabilities, including validation, trading partner management, and other functions that may be required to address broader organization needs.Next, our Edifecs5010 Testing solution, which incorporates our guideline authoring and publication tool, SpecBuilder, our secure testing portal, Ramp Management, our Transaction Management solution for visibility into end-to-end testing processes and results, and our free Edifecs5010 Compliance Online testing and certification solution.Finally, Perficient offers Edifecs trained consulting services, bringing business and technical experts who are well-versed in all aspects of our solution, best practices, and integration patterns into existing infrastructures, based on our experience with many customer implementations.
  • The Step Up / Step Down solution is available in a range of options, allowing clients to select the option that is most relevant to their specific needs.In the Foundation version of Step Up / Step Down, the organization has no need to perform validation on the inbound or outbound transactions, but has a short-term need for processing both 4010A1 and 5010 versions of the mandated transactions. This version includes our pre-built maps for both 4010A1 and 5010 conversion to their counterparts, our SpecBuilder map designing tool, our translator, and consulting services to implement this solution.The Standard Step Up / Step Down version is for the most robust implementation needs, where the organization requires full validation, translation and trading partner management capabilities. In the Enterprise version, the solution delivers the pre-built conversion maps, the map designing and guideline authoring tools, the full XEngine validation and translation tools, the Transaction Management and Trading Partner Management applications, along with the Perficient consulting services required for implementation.Sudhir will be demonstrating our Step Up / Step Down full version later in the webinar.
  • Perficient understands that testing can serious expand a 5010 migration project. We also understand that creating test data can slow down or stall a fast moving migration and increase the testing costs at the same time. The Edifecs toolset is designed to address these key concerns for testing and our experienced team can help capitalize on the strengths of the tool set, especially creating test data sets.
  • The Edifecs5010 Testing Solution is available to help organizations achieve the two compliance milestones as defined by CMS in the Final Rule. For Level One Compliance, those internal testing and development needs might include converting individual 4010 test or production files to 5010 test cases, creating and migrating edits to your 5010 Companion Guides, testing acknowledgements and any file splitting that may be need to be done for multiple back end environments. For Level One Compliance, the Edifecs5010 Testing Solution includes guideline creation and migration tools, test data generation and 4010 to 5010 data conversion, visibility to testing results, validation of test transactions during system testing, and an internal user portal where multiple teams can access your guidelines and test cases, and upload and test transactions for compliance with WEDI-SNIP types, as well as your business rules.For external testing, Edifecs5010 Testing Solution can be extended with the Edifecs Transaction Management product, to provide visibility into the full end-to-end testing cycle with trading partners, to achieve and document Level Two compliance. This last point, Documentation, is very important, and not just for 5010 – the recent healthcare reform legislation requires documentation of end-to-end testing with trading partners for compliance with transaction “Operating Rules” that will be mandated by HHS over the next 6 years, on a phased basis. At this point, I want to introduce Sudhir. He is the Director of Solutions Consulting at Edifecs. Sudhir has more than 12 years of experience in the Healthcare Technology space and has a focus on building solutions in the areas of SOA, BPM, E-Commerce and Enterprise Applications. Sudhir has been with Edifecs for nearly 2 years and is primarily responsible for the designing of strategic solutions for customers by applying the Edifecs solutions and products to their pain points. He will be conducting today’s demonstration. Please welcome Sudhir.
  • For many organizations, external testing is a very complex and resource intensive activity. With one of our customers, we did an time study analysis to compare their “before” process for external testing, with the “as-is” process using our Unified Testing solution.In this case, our customer was able to document that in the “before” process, it took an average of 17 man-hours to migrate a trading partner, compared with a 35 minute process using our Edifecs Unified Testing. This savings of over 16.5 hours for a single trading partner created a huge Return on Investment, and allowed the customer to use precious development, testing, and business resources to more value-added activities – an 85% reduction in time spent per trading partner migrated.
  • Hello and welcome to this demonstration of the Step Up – Step Down solution. During this demo we will show you how the Step-Up/Step-Down solution seamlessly translates between 4010A1 and 5010 and helps you achieve 5010 compliance without the need for remediating core processing systems.For this demo let’s consider the following scenario:Let’s say we are a Health Plan called the “Healthy Life Plan”We have two trading partners (1) The Mayo Clinic and (2) Stanford Hospital. We do business with both these partners through a clearinghouse called ICH.The Mayo Clinic sends us claims in the new 5010 format and Stanford Hospital Mayo Clinic sends us their files in the 4010 format. These claims are collected by the clearinghouse and sent to us as discrete transmissions.We as the Healthy Life Plan take all of the claims sent to us, validate them, translate them depending on the requirements of our core processing system and then route them to the appropriate adjudication system. We will assume that we have both a legacy 4010 core processing system (called System A) and a 5010-capable processing system (called System B)Based on the incoming claims our core processing systems will generate the appropriate 835 claim payments. These will go through the same processes that the incoming claims went through in reverse order before being sent to the correct trading partner.Now, we can see that this solution sits at the front-end of our IT infrastructure, and we want this to be able to transport all of the incoming and outgoing transactions in a fast and effective manner, without any loss of data.For this scenario therefore, our solution must provide:Lossless translation from 4010A1 to 5010 and vice versa, andComplete end-to-end view into all transactions, including the translated transactions, processing steps and eventsOur goal for today’s demonstration is to show you how the Edifecs SUSD solution provides these key capabilities.
  • We will demonstrate these capabilities using a User Story. We will assume that we are a CSR within the Healthy Life Plan who receives a call from a Patient Account Representative at our trading partner, the Mayo Clinic about a missing claim payment. We will then help them find the correct claim payment by reviewing the entire transaction lifecycle of the claim. In this story, we will basically highlight the following features and benefits of the solution:The ability to Search and Filter across all incoming and outgoing transactions exchanged with trading partners.Validation of 4010A1 and 5010 transactions and Lossless Translation between both standards. Here we will mainly focus on how the Pre-Built maps within the SUSD solution enrich 5010 transactions with any data that was lost in the 5010-4010 Step-Down process. This is important because Edifecs ensures translation accountability and data integrity in a SUSD solutionBatching and appropriate routing to the Core Processing System that is able to handle the transactionsSo, let’s go into our first scenario. We’re the CSR at Healthy Life Plan and we receive a call from Mayo Clinic. They say they are missing payment for a claim that was sent to us through their clearinghouse ICH.To resolve this problem, we need to:Check if we really did receive the claim from themReview the entire path of the claim through various processing events i.e. through validation, translation and routing to the right adjudication system, and thenFind the payment that was generated by the adjudication system as a response to our claimWe can then provide those details to the PAR so they can follow up with the clearinghouse to resolve the issue
  • Just as a quick review, at Perficient we see the Edifecs Step Up/Step Down solution combined with our experienced team as a means to quicly reclaim the regulatory deadlines for your organization. The speed with which this solution can be implemented and especially it’s ability for parallel testing of 4010A1 and 5010 transactions will buy valuable time for competing IT projects and a more controlled pace of change.
  • One key added value from Perficient is our expertise in healthcare analytics. That expertise can develop the analytic reports to compare 4010A1 and 5010 transactions – and let your CFO sleep at night. In addition, our analytics can help develop the reporting processes required by your trading partners. We have a specialized performance testing team that understands the EDI transactions, their related business processes and how to hunt down bottlenecks in day to day transaction processing.
  • Let Perficient’s Healthcare team be your rapid response to jumpstarting your 4010 to 5010 migration! We appreciate your time today and now we will take questions. While you are creating your questions in the chat window, I want to get you thinking about these questions as well.
  • HIPAA 4010 a1 to 5010 migration

    1. 1. HIPAA 4010A1 to 5010 Migration:Rapid Compliance with a Step Up/Step Down Approach<br />
    2. 2. About Perficient<br />View a Recording of this Webinar and others at Perficient.com/Webinars<br />Perficient is a leading information technology consulting firm serving clients throughout North America. <br />We help clients implement business-driven technology solutions that integrate business processes, improve worker productivity, increase customer loyalty and create a more agile enterprise to better respond to new business opportunities. <br />
    3. 3. PRFT Profile<br />Founded in 1997<br />Public, NASDAQ: PRFT<br />2009 Revenue of $188 million<br />18 major market locations throughout North America<br /><ul><li>Austin, Chicago, Cincinnati, Cleveland, Columbus, Dallas, Denver, Detroit, Fairfax, Houston, Indianapolis, Minneapolis, New Orleans, Philadelphia, San Francisco, San Jose, St. Louis and Toronto</li></ul>1,400+ colleagues<br />Dedicated solution practices<br />~450 enterpriseclients (2009) and 85% repeat business rate <br />Alliance partnerships with major technology vendors<br />Multiple vendor/industry technology and growth awards<br />
    4. 4. Our Solutions Expertise & Services<br />Business-Driven Solutions<br />Enterprise Portals<br />SOA and Business Process Management<br />Business Intelligence<br />User-Centered Custom Applications<br />CRM Solutions<br />Enterprise Performance Management<br />Customer Self-Service<br />eCommerce & Product Information Management<br />Enterprise Content Management<br />Industry-Specific Solutions<br />Mobile Technology<br />Security Assessments<br />Perficient Services<br /><ul><li>End-to-End Solution Delivery
    5. 5. IT Strategic Consulting
    6. 6. IT Architecture Planning
    7. 7. Business Process & Workflow Consulting
    8. 8. Usability and UI Consulting
    9. 9. Custom Application Development
    10. 10. Offshore Development
    11. 11. Package Selection, Implementation and Integration
    12. 12. Architecture & Application Migrations
    13. 13. Education</li></ul>Perficient brings deep solutions expertise and offers a complete set of flexible services to help clients implement business-driven IT solutions<br />
    14. 14. Our Speaker<br />Martin Sizemore<br />Enterprise Architect with specialized skills in Enterprise Application Integration (EAI) and Service Oriented Architecture (SOA). <br />Martin has been a consultant and trusted advisor to CEOs, COOs, CIOs and senior managers for global multi-national companies and healthcare organizations.<br />His deep industry experience as a consultant in manufacturing, healthcare and financial services industries has provided him with a broad knowledge of IBM hardware and software offerings with numerous certifications and recognitions from IBM including On-Demand Computing and SOA Advisor. <br />He is experienced with Microsoft general software products and architecture, including SharePoint and SQL Server and has worked closely with Microsoft architects on healthcare products including their healthcare CRM, Amalga, and HealthVault offerings. <br />
    15. 15. Today’s Agenda<br />Define challenges facing organizations with a 4010A1 to 5010 Migration<br />Examine Choices for a Solution<br />Review the Edifecs Step Up/Step Down Solution<br />How this approach addresses the challenges<br />Pros and Cons <br />Next Steps<br />
    16. 16. Recommended Tasks and Timelines<br />5010 Final Compliance<br />L2<br />Strategy and Assessment<br />Design & Build<br />Internal Testing<br />External Testing<br />Conversion (Dual-Mode)<br />Training and Outreach<br />12/31/2010<br />01/01/2012<br />12/31/2011<br /> ICD-10<br />Compliance<br />10/01/2013<br />Program Management<br />We are here<br />L1<br /><ul><li>The timelines depicted above are illustrative only. The size of the organization and the level of impact would determine more realistic timelines</li></li></ul><li>Challenges<br />Regulatory deadline pressures<br />Competing with large IT projects<br />EMR implementations, claims processing modernization<br />Lack of experienced professionals with EDI X12 experience<br />Having 4010A1 and new 5010 transactions match for billing and A/R<br />Audit risk from government agencies<br />Waiting on software application vendors for ICD-10 upgrades<br />Many delayed until 2012 <br />Will need extensive testing<br />
    17. 17. Solution Choices<br />Providing options for 5010 Compliance<br />1<br />2<br />3<br />While each option has pros and cons, many organizations are exploring Step-Up/Step-Down solutions to mitigate risk.<br />
    18. 18. Our Solution<br />Subject Matter Expertise<br /><ul><li>Business processes
    19. 19. HL7 transactions
    20. 20. Trading partners</li></ul>Toolset to automate 5010 processing <br /><ul><li>Reduces manual effort
    21. 21. Reduces testing effort
    22. 22. Improves speed to implement</li></ul>Tailored Approach<br /><ul><li>Assessment of current state, gap analysis
    23. 23. 4010, 5010 parallel processing
    24. 24. Best practices</li></li></ul><li>Perficient’s Edifecs Partnership<br />Edifecs5010™ Step-Up/Step-Down Solution<br />Simple Translation Capabilities<br />Enterprise Capabilities<br />Edifecs5010™ Testing Solution<br />Edifecs SpecBuilder<br />Edifecs Ramp Management<br />Edifecs Transaction Management<br />Edifecs5010™ Compliance Online<br />Edifecs Trained Consulting Services from Perficient<br />World-class service professionals who are deeply conversant with HIPAA 5010 and trained in the latest technologies.<br />
    25. 25. Achieving HIPAA Compliance<br />Requirements<br /><ul><li>Accept inbound 5010 transactions and convert to 4010A1
    26. 26. Transaction Enrichment
    27. 27. Full validation required for transactions
    28. 28. View all transactions for ongoing visibility and auditing needs
    29. 29. Dual-use capabilities (accept both 4010A1 and 5010 transactions)
    30. 30. Trading partner management capabilities</li></ul>Standard<br />Version<br />Solution Components<br /><ul><li>Pre-built 4010A1-5010 maps
    31. 31. Edifecs SpecBuilder
    32. 32. Edifecs XEngine Translator
    33. 33. Edifecs Transaction Management
    34. 34. Edifecs Trading Partner Management
    35. 35. Consulting Services</li></ul>Solution Components<br /><ul><li>Pre-built 4010A1-5010 maps
    36. 36. Edifecs SpecBuilder
    37. 37. Edifecs XEngine Translator
    38. 38. Consulting Services</li></ul>Translation<br />Requirements<br /><ul><li>No need to validate transactions
    39. 39. Need short-term solution for processing both 4010A1 and 5010 transactions</li></ul>Foundation<br />Version<br />
    40. 40. Testing Challenges<br />Testing will account for 70% of HIPAA 5010 implementation costs (Gartner)<br />Building test data represents a significant portion of overall testing costs<br />Manual tasks to create and maintain test data drive up costs and decrease efficiency<br />Hours By Phase of Testing<br />Source: Edifecs Customer<br />
    41. 41. HIPAA Compliance Testing Solution<br />5010 Level 2 Testing (External)<br />Requirements<br /><ul><li>Trading Partner Management
    42. 42. External Transaction Testing
    43. 43. Complete front-end testing
    44. 44. Migration Dashboard/Reporting
    45. 45. Test linking inbound and outbound transactions</li></ul>Solution Components<br /><ul><li>SpecBuilder
    46. 46. Publish Guidelines
    47. 47. XEngine
    48. 48. Validation
    49. 49. Ramp Management
    50. 50. Easily onboard and test with Trading Partners
    51. 51. Transaction Management
    52. 52. Maintain Visibility
    53. 53. Manage Trading Partners</li></ul>5010 Level 1 Testing (Internal)<br />Requirements<br /><ul><li>Convert 4010A1 test files to 5010
    54. 54. Test companion guides
    55. 55. Test SNIP edits
    56. 56. Test acknowledgment generation
    57. 57. Test file splitting
    58. 58. Test Data creation and management</li></ul>Solution Components<br /><ul><li>SpecBuilder
    59. 59. Create and Test Guide Lines
    60. 60. Analyze Results
    61. 61. XEngine
    62. 62. Validation
    63. 63. Test Management
    64. 64. Create and manage test data
    65. 65. Ramp Management
    66. 66. Test files</li></li></ul><li>Case Study: External Testing<br />28% of survey respondents have over 500 Trading Partners to onboard<br />Total trading partner onboarding time reduced from 17+ hours to 35 minutes<br />
    67. 67. Business Process Flow<br />837 Process<br />4010 Claims batch from Stanford & Mayo combined<br />Adjudication System A<br />(accepts 4010 only)<br />4010 batch for Sys A and Sys B<br />Clearinghouse<br />Stanford Hospital<br />Validation<br />Translation<br />Batching Routing<br />Web / FTP<br />Adjudication System B<br />(accepts 5010 only)<br />Mayo Clinic<br />5010 batch for Sys A and Sys B<br />5010 Claims batch from Stanford & Mayo combined<br />835 Process<br />System A (Generates 4010 Remittance Advice)<br />4010 Remittance batch for Stanford & Mayo<br />4010 batch of Remit Advices<br />Stanford Hospital <br />Clearinghouse<br />Splitting Routing<br />Translation<br />Validation<br />Web / FTP<br />Mayo Clinic<br />System B<br />(Generates 5010 Remittance Advice)<br />5010 Remittance batch for Stanford & Mayo<br />5010 batch of Remit Advices<br /><ul><li>Lossless Translation
    68. 68. End-to-end view of transaction flow</li></li></ul><li>Use Case Scenario<br />Patient Account Representative (PAR) inquires about missing Claim Payment<br />Highlighted Benefits of the Step-Up/Step-Down Solution<br />Ability to Search and Filter across all incoming and outgoing transactions exchanged with trading partners<br />Validation of 4010A1 and 5010 transactions and Lossless Translation between both standards (Pre-Built Maps)<br />Batching and appropriate routing<br />Steps for resolving the PAR’s problem<br />Check if we really did receive the claim<br />Review the entire path of the claim through various processing events i.e. through validation, translation and routing to the right adjudication system<br />Find the payment generated by the adjudication system as a response to our claim<br />Provide details to the PAR so they can follow up with the clearinghouse<br />
    69. 69. Architectural View of a Step-Up/Step-Down Implementation<br />Major Advantages: Speed, no “Rip and Replace” of existing systems and parallel testing of 4010A1 and 5010 transactions to assure proper billing and A/R<br />
    70. 70. Added Value from the Perficient Approach<br />Leverage our healthcare analytics knowledge to develop add-ons to the Edifecs5010™ Solution to provide assurance to for 4010A1 to 5010 Migration.<br />Key example: Edifecs Healthcare Transaction Repository (HTR) is a consolidated repository of 100% of the 4010A1 and 5010 transactions stored in a business-normalized schema.<br /><ul><li>Perficient can develop analytical reports to compare the 4010A1 and 5010 transactions each day, week or month to assure the Chief Financial Officer that revenue and billing are under control
    71. 71. Perficient can develop reports to analyze transactions by trading partner to balance transmissions inbound and outbound to the organization
    72. 72. Perficient can develop reports to support the testing and quality assurance effort and re-use them for multiple clients
    73. 73. Perficient can manage the performance testing of 5010 solutions</li></li></ul><li>Solution Evaluation<br />Pros<br />Rapid deployment for “late starters”<br />Allows a phased approach to remediation on your schedule<br />Defers total cost of 5010 remediation into more managed phases<br />Edifecs has integration capabilities beyond 4010 to 5010 migration<br />HL7 Interoperability, XML<br />Cons<br />Still not an “easy” solution – requires planning, implementation and testing<br />Typically the solution requires EDI subject matter expertise<br />Professional services may be needed to speed implementation to meet deadlines<br />Small amount of “back end” systems remediation is needed<br />
    74. 74. Next Steps<br />What are the biggest risks to your 5010 implementation right now?<br />Were there any areas of the problem space or solution that the Edifecs solution does not address?<br />When do you plan on starting with external testing?<br />Q&A<br />
    75. 75. Follow Perficient Online<br />Perficient.com/SocialMedia<br />Daily unique content about content management, user experience, portals and other enterprise information technology solutions across a variety of industries.<br />Twitter.com/Perficient<br />Facebook.com/Perficient<br />
    76. 76. Thank You!<br />