Icd 10 implementation and business final slideshare

ICD-10The Different Dimensions of

Business Continuity PlanningPresented by Mike Arrigo

Managing Partner, No World [email protected]

July 21, 2011 WEDI Implementation Forum

Advancing Down the Implementation Highway:Merging into 5010 Compliance, Shifting into ICD-10

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ICD-10 BCP Topics

Three constraints for ICD-10

Five principles of BCP and ICD-10

Five dimensions, 25 risk areas

Post mandate risks for ICD-10

Opportunities with ICD-10

Next Steps for ICD-10 implementations

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Unique Challenge of ICD-10

Three Constraints, Single Compliance Date

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Compliance Iteration & InnovationVs.


Five Principles of BCP

Business

Impact Analysis

Plan Development & Execution

BCP LIFE

CYCLE

Test Plan

Maintenance

Plan

Business

Impact

Analysis

Risk

Assessment

Strategy

Selection

Plan

Development

& Execution


Business Continuity Planning for ICD-10

Business

Impact Analysis

Plan Development & Execution

ICD-10 BCP LIFE

CYCLE

ICD-10 Testing

Post Live 10/1/2013

Support

High Level Review,

Gap Analysis

ICD-10 Risk Assessment

ICD-10 Business Impact

Assessment

ICD-10 Business Roadmap

& Strategy

ICD-10 Implementatio

n

Plan

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Risk Mitigation

Risk identification & trigger events

Risk Mitigation Planning

Examples of the 5 dimensions, 25 Risk

Areas



The 5 to 6 Risk Areas

Payor Perspective (5)

Governing bodies Submitter (clearinghouse,

providers, testing, contracting, etc.)

Payors (inter-plan partners, payor to

payor COB, Out of Network, CMS crossover, worker’s comp, life…)

Internal (org change, roadmap,

governance, clinical, actuarial, UM, CM, IT, ops, etc.)

Operational stabilization (post 10/1/2013 go-live)

Provider Perspective (6)

Governing bodies Patients (workflow: intake,

assessment, coding, documentation, referral, discharge, billing, collection, EMR)

Payors (contracting, testing, etc.)

Internal (org change, physician

outreach & education, coders, UM, CM, roadmap, governance, clinical, IT, ops, etc.)

Operational stabilization (post 10/1/2013 go-live)


ICD-10 Key Risks (page 1 of 3)

Excerpts from 25 Risk Assessment Areas

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Risk Risk Trigger Event Remediation / Mitigation

HealthCo staff are not trained in ICD-10 impacts

Training evaluation shows lack of knowledge (by 12/31/2011).

Retrain as necessary

Providers are not ready to submit ICD-10 codes

Provider assessments and external testing show lack of provider preparedness.

1.Assure systems can handle ICD-9 for post 10/1/2013 services/prepare business continuity plan

2.Work with ClearingHouseX and others to move providers forward

Vendor readiness / capabilities don’t meet SLAs

Vendors do not deliver ICD-10 ready products by agreed upon date or do not provide the appropriate functionality.

1.Look for alternative vendors

2.Develop in house capability

3.Negotiate acceptable revised dates and monitor

4.Dashboard of delivery dates



Excerpts from f 25 Risk Assessment Areas

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Payor financial risk – payments are significantly higher than anticipated

Benefit payments for post Oct. 1 2013 services from Oct. 1 – Dec. 31, 2013 significantly higher than anticipated and impact HealthCo ability to pay.

1.Assure sufficient cash reserves prior to Oct 1, 2013

2.Possibly acquire line of credit

3.Negotiate contingencies with providers

4. Understand changes to DRGs, Case Rates, APGs

Provider financial risk – reimbursements are significantly lower than anticipated

Benefit payments for post Oct. 1 2013 services from Oct. 1 – Dec. 31, 2013 significantly lower than anticipated and impact provider’s ability to operate as a business.

1.Communicate with payors to prepare for this

2.Negotiate contingencies with payors

3.Negotiate for periodic interim payments

4.Contracting calendar



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Excerpts from 25 Risk Assessment Areas

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• HealthCo productivity reduced due to ICD-10

• May see increase in paper claims.

• As of 12/31/13, HealthCo worker productivity and claims processing turnaround significantly impacted.

• Increase in claims backlog and payment delays.

1.Prepare for additional hiring, at least temporarily

2.Determine causes of slowdowns and revise processes as necessary

3.Conduct virtual operational testing to assess productivity issues prior to go-live



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Mitigate Vendor Impacts

Don’t assume “ICD-10 Compliant” vendors have solved all of your problems

Vendor testing– SLAs – do they support your test cycle and

break / fix approach?– Release dates?– Include vendors in end to end business test

plan

Dashboard the collisions and conflicts in release dates, interdependencies


Example: Project DashboardRisk: ICD-10 Vendor Impacts

TT

OCT 837 JAN 835 APR 834 NOV 999 FEB 270/271 MAY 278 TESTING NOV TA1 MAR 276/277 JUN 820 DEC 277CA

OCT 837 JAN 835 APR 834 NOV 999 FEB 270/271 MAY 278 TESTING NOV TA1 MAR 276/277 JUN 820 DEC 277CA

Qtr 4Qtr 2Qtr 1Qtr 4Qtr 3Qtr 2Qtr 4Qtr 3Qtr 2Qtr 1 Qtr 1 Qtr 3

Analysis → ICD-10 Implementation → Testing → Go-LiveAnalysis → ICD-10 Implementation → Testing → Go-Live

Qtr 3

HealthCo provider lookup

HealthCo provider lookup

Syste

m U

pg

rades

Prod 01/2012

4010 → 5010 Migration

Vendor AVendor A Vendor BVendor B Vendor CVendor C

Vendor D prod 1Vendor D prod 1 Vendor D, prod 2Vendor D, prod 2 Veendor D, prod 3Veendor D, prod 3

Vendor X, RFPVendor X, RFP

Vendor EVendor EVendor Y(RFP?)Vendor Y(RFP?)

Vendor FVendor F

Vendor GVendor G

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Example of Post October 1, 2013 Issue

ICD-10 Updates

At ICD-9-CM Coordination & Maintenance Committee Meeting (9/15/10) partial freeze for both ICD-9-CM and ICD-10-CM

On 10/1/2014 - updates to ICD-10 will begin

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Example of ROI Items (page 1 of 2)

Real World Examples

Opportunity Benefit or Recommendation

• Research ability to change reimbursement method from percent of billed charges to using DRGs based on ICD-10.

• Need to capture ICD-9 now and ICD-10 in the future.

• Better visibility into services being rendered and analysis of charges against industry standards.

• Capturing ICD-10 codes will also deliver valuable information for improving wellness programs, which translates into health cost savings.

• Overall risk and issue identification from ICD-10 initial review.

• HealthCo staff had meaningful take-aways.

• Knowledge sharing took place between teams.

• Medical Management team responded with interest in developing improved health risk identification systems based on new ICD-10 codes.

• Training team will begin discussions on viability of current systems and materials to support new ICD-10 training.

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ROI Items Identified (page 1 of 2)

Real World Examples

Opportunity Benefit or Recommendation

• Raised executive awareness of ICD-10 project impacts and resource challenges.

• Presented organizational tool that will be given to HealthCo as part of project.

• Oversight committee better prepared for handing two major projects (5010 & ICD-10).

• Business Roadmap sessions delivered executive level education on developing organizational initiatives.

• Repeatable process for planning prioritization.

• Efficiencies so senior management direction given to execution team

• Ensures team is aligned with and working toward organization goals

• Awareness of opportunities and innovation with ICD-10

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Next Steps


Mapping Observed Changes

Before Assessment During Assessment Remediation Plan thru October 1, 2013

While HealthCo made great strides in the last 90 days, the organization must continue forward progress.

1.HealthCo had low awareness of impact and opportunities of ICD-10.

2.Too many answers were in the “Don't Know” category in the web survey.

3.Urgency for change appeared quite low.

4.Communication levels re: ICD-10 seemed to be very low.

Ensure regular project management, governance, and requirements development activities are initiated immediately.

These activities must be reviewed monthly and quarterly, with regular management oversight.

Failure to start these activities will result in regression to where the organization was in August 2010.

Training plans as recommended should be prioritized by functional area.

Continue Business Roadmap activities for areas not yet prioritized:1. Plan2. Prioritize3. Prerequisite plan4. Implementation plan for prioritized items

Overall ICD-10 Implementation:1. Steering committee meeting schedule2. Establish project management coordination group3. Establish implementation team org chart, team roles, 4.Recruit, retain, identify team members5.Iterative review and editing of the project timeline

Determine ICD-10 work coordination process:1. Frequency of communication, coordination of issues2. Project governance and standards3.Development and review of requirement artifacts

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Training as a Risk Mitigation Strategy

Example of Business Areas to Train

Medical Management Actuarial Benefit coverage Payment policies Payor / Provider Relations Claims processing Statistical trending Fraud and Abuse Budget estimation Quality measurement Waiver programs and Case Management

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ICD-10 Example Impact Assessment Functional Areas with the Most Risk

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Risk Mitigation: Clearly Identify Roles for Payor, Provider Work Teams for ICD-10

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Risky thinking: “I need a good ICD-10 project manager….”

Comment: “Yes, but there are other organizational competencies needed…”

See http://slidesha.re/icd10orgstrat



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Provider Specific Factors for ICD-10(Excerpt from Assessment)



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ICD-10 and Documentation Provide audit trail of assumptions

Mitigate punitive regulatory impacts

NAIC Audit Rules, Sarbanes Oxley – Revenue impacts– Medical Loss Ratio

Selected areas for document trail– Board and management minutes– Risk assessment and documentation– Business continuity plan documentation– Back up procedures– Service provider contracts, SLAs– Testing plans


What’s next?


Discovery & Remediation Tools:•COBOL•.NET•Java

9 to 10 Frameworks:•Vocabulary •Concepts•Consortiums

Testing:•Leverage 5010 / ICD-10•End to end



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Bottom Line

ICD-10 is a major enterprise effort requiring best practice planning

Only one chance go get ICD-10 right with single compliance date of 10/1/2013

Some organizations believe they will be forced to take short cuts because there is a shortage of time and resources to do it 'right.’

Use BCP principles to mitigate risk


Mike ArrigoManaging Partner, No World

[email protected]

949-335-5580 x1001Recorded webinar on BCP and ICD-10

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