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Technical Advisory Group (TAG). December 11, 2013 Dr. Daniel Lessler, Chief Medical Officer. ICD 10 Implementation. Paul Price [email protected] Project Manager. ICD10 Diagnostic Codes October 1, 2014. CMS Mandated Change All HIPAA covered entities - PowerPoint PPT Presentation
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Technical Advisory Group Technical Advisory Group (TAG)(TAG)
December 11, 2013
Dr. Daniel Lessler, Chief Medical Officer
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Technical Advisory Group (TAG) Meeting Agenda
March 12, 2014 / 10:00am to 11:30am
To Register: https://www2.gotomeeting.com/register/842771506
Presenters: Medicaid, Labor and Industries, Centers and Medicare and Medicaid Services,
No. Topic Highlights
1.
Introduction
Chief Medical Officer, HCA, Dr. Daniel Lessler
Welcome and Introductions 5 min
2.
HCA
ICD-10 Project Manager, Paul Price
ICD-10 Implementation at HCA
20 min
3.
L&I Occupational Health Services Manager,
Diana Drylie
Policy & Payments Manager, Erik Landaas
ICD-10 Update
Best Practices
25 min
4.
HCA
Section Manager/QCM, Alison Robbins
Health Care Services, Director, Preston Cody
Medicaid Managed Care Contracts Overview
20 min
5.
CMS, Region 10
Chief Medical Officer, Dr. Nancy Fisher
CMS Updates
15 min
ICD10 Diagnostic CodesICD10 Diagnostic CodesOctober 1, 2014October 1, 2014
• CMS Mandated Change• All HIPAA covered entities• 9/30/14 - last date-of-service for ICD9 codes• 10/1/14 - first date-of-service for ICD10
codes• Deadline was delayed 1 year• CMS says no more delays• HCA WA Medicaid planning on 10/1/2014
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OverviewOverview
• Diagnosis/PCS Codes – Analysis/Remediation– In-House Review and Remediation– CNSI Review and Remediation
• Medicaid Provider Guides – Update• Providers/Plans – Outreach and Testing
– Listserv messages– Website content– Testing instructions
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Partners & StakeholdersPartners & Stakeholders
• CMS Noblis - Guidance and Support• OneHealthPort – Plans/Providers
Discussions• Health Plans – Encounter Processing• Hospitals & Providers– End to End
Testing• Medicare – Cross Over Claims
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TimelineTimeline
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Clinical Review / Mapping of 2012
Vendor CR 2 – Design, Dev, Test, Impl
Provider Communications and Readiness
Provider Testing
Medicaid Provider Guide Review and Update
Nov
Go Live!
Vendor Analysis
Vendor CR 1 – Design, Dev, Test, Impl
Dec Jan Feb Mar Apr May Jun Jul Aug Sep OctPrior
OMSD Program Review
RFP QA & IVV
Staff Recruiting
Vendor- UAT
HCA In-House – P1 Design, Dev, Test, Impl
HCA In-House – P1 UAT
UAT - Contingency
Clinical Review & Support
ICD-10 Conversion
Technical Advisory Group update
L&I will convert from ICD-9 to ICD-10 effective October 1, 2014
Although worker’s compensation is technically exempt, L&I is converting to ICD-10 to align with industry standards. Doing so will:– Minimize the administrative burden to medical
providers by not requiring them to maintain a separate billing system using ICD-9 codes
– Result in the allowance of more accurate diagnoses on claims
– Result in more precise data collection by L&I
Key Dates September 1, 2013
– ICD-10 end to end testing with trading partners begins
March 17, 2014– L&I begins testing internal ICD-9 to ICD-10 conversion process
April 1, 2014– All State Fund bills must be submitted in the 5010 format.
July 1, 2014 – Department makes the new CMS 1500 form available
August 1, 2014– Department begins conversion of ICD-9 codes to ICD-10 codes
October 1, 2014– Compliance date for ICD-10 CM– New CMS 1500 form becomes manditory
Resources at Labor & Industries Additional information can be found at
– www.lni.wa.gov
– www.onehealthport.com
If you have specific questions, please contact
– Emily Stinson• 360-902-5974 [email protected]
– Shalene Petrich• 360-902-5651 [email protected]
COHE Expansion and New Best Practices: L&I Updates
Diana Drylie, Occupational Health Services Manager
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Highlight of L&I Quality Efforts 2013 and Beyond
COHE Expansion
New Best Practices
Top Tier
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2011 Workers Comp Reform Legislation: Substitute Senate Bill 5801
Reduce disability by providing higher quality medical care
Promote occupational health best practices
Improve worker outcomes
Background on Reform
Goals:
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Substitute Senate Bill 5801:Key Provisions
Designate a “top tier” and provide incentives for network providers who demonstrate best practices
Expand Centers of Occupational Health & Education (COHEs)
Create a tracking system for occupational-health best practices in COHE and Top Tier
Identify and pilot emerging best practices
The new law directs L&I to:
Distribution of Quality of Care
Clinical Efficiency
PoorGood
Com
mun
ity
Phy
sici
ans
Zone 1 Zone 2 Zone 3 Zone 4
Excellent Health and Disability Outcomes
Moderate or Average
Medical and DisabilityCosts
Questionable Health/
Disability Outcomes
Average Medical and Disability
Costs
Poor Health and Disability Outcomes
Average to High Medical and
Disability Costs
Very Poor Health/Disability Outcomes
High Medical and Disability
Costs
(Quality & Value)
• COHE High Adopters•COHE Model: Identify high performers to serve as mentors
• COHE High Adopters•COHE Model: Identify high performers to serve as mentors
•COHE MODEL plus• Incentives for quality indicators known to improve outcomes• Resources to help docs apply them (CME, HSCs, reminders)• Geared toward improving well-intentioned Zone 2 & 3
•COHE MODEL plus• Incentives for quality indicators known to improve outcomes• Resources to help docs apply them (CME, HSCs, reminders)• Geared toward improving well-intentioned Zone 2 & 3
Network Minimum Standards
Risk of Harm
Education and other interventions
Network Minimum Standards
Risk of Harm
Education and other interventions
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Purpose and Goals
COHE Expansion
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Expanding Access to COHE Services
The 6 current COHEs will serve 38 counties :
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Access to COHE Services
Current # of Enrolled Providers
Proposed # of Enrolled Providers COHE Name
1,219 1,451 Eastern Washington COHE at SLRI/INHS
222 230 The Everett Clinic COHE
36 70 Group Health Cooperative COHE
184 233 Harborview Medical Center COHE
269 300 Renton COHE at Valley Medical Center
195 1,208 Western Washington COHE at Franciscan
2,125 3,492 TOTAL
COHE Provider Enrollment (as of December 23, 2013)
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Expanding Access to COHE Services
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Expanding Access to COHE Services
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Purpose and Goals
New Best Practices
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Emerging Best Practices: Current Pilots
http://www.lni.wa.gov/ClaimsIns/Providers/Reforms/EmergingBP/#2
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Emerging Best Practices: Current Pilots
http://www.lni.wa.gov/ClaimsIns/Providers/Reforms/EmergingBP/#3
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Emerging Best Practices: Upcoming Pilot
Emerging Surgical Best Practices
Four best practices selected from the literature by a focus group of attending providers & surgeons related to: Transition of Care Return to Work
Creation of a Surgical Health Services Coordinator to: Coordinate care and transitions Help providers with complicated cases
http://www.lni.wa.gov/ClaimsIns/Providers/Reforms/EmergingBP/#4
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Purpose and Goals
Top Tier
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Top Tier Visual
COHEIniti
al V
isit
Prov
ider
Provider Network
Top Tier
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TOP TIER
Give incentives to providers for demonstrated use of best practices
Top Tier Goals– Increase the use of best practices– Achieve positive outcomes for injured workers– Be simple for providers to understand and L&I to administer– Align with other incentive programs (such as COHE)
Advisory Group (ACHIEVE) Items for Dissions– Top Tier Timing– Top Tier Eligibility– Top Tier Incentives– Top Tier Administration
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COHE Expansion and New Best Practices
Washington Apple HealthWashington Apple HealthManaged Care – 2014 ContractManaged Care – 2014 Contract
March 12, 2014March 12, 2014
Enrollee AssignmentEnrollee Assignment
• January 1 – June 30, 2014– Assignment based on percentage of
enrollment (25% or greater only receive assignment when there are not MCOs with less than 25% in service area;
– Network adequacy also a factor in assignment
• MCO must have 80% coverage or higher for enrollment and assignment
• 60% and above for enrollment only• <60% no enrollment or assignment
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Assignment changes for Assignment changes for July 1, 2014July 1, 2014
• July 1, 2014 begins assignment based on HCA’s analysis of MCO’s self-reported performance measure on completion of initial health screens
• MCOs will report screening performance for Jan/Feb on April 10 for July assignment; Mar/April on June 10 for August assignment, etc
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ABP and other Benefit ABP and other Benefit ChangesChanges
• Habilitative services added to benefits for Medicaid Expansion enrollees
• Shingles vaccine added for enrollees age 60 and over
• Family planning drugs, supplies, devices dispensed in 12 month supplies
• Mental health benefit modified to reflect mental health parity requirement
34
Mental Health ParityMental Health Parity
• Previous mental health benefit: Evaluation plus 12 visits/year for adults; 20/year for children
• New benefit: MCOs authorize MH visits in same manner as other therapies; visits are limited by medical necessity
• Coordination required between MCOs/ RSNs;
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Mental Health Parity/2Mental Health Parity/2
• 2014 contract requires close coordination and transition activities between systems– MCO assesses enrollee requesting MH
services to determine potential for meeting Access to Care Standards (ACS) and authorizes Medically Necessary Services
– If enrollee appears to meet ACS, transition to RSN is made so enrollee maintains greatest degree of continuity of care with providers
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Payment and SanctionsPayment and Sanctions
• Update and clarify risk adjustments including Risk Mitigation Strategy for Expansion Population
• Addition of a Low Birth Weight Baby Case Payment – one time payment made for LBW babies based on specific AP-DRG codes. Maximum 470 payments/year
• Update and clarify Encounter Data submission requirements
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WA HCA TAG
March 12, 2014
Nancy L. Fisher, MD, MPH
CMO. Region X
Competitive Bidding Implementation Open Payment Program (Sunshine Act) ICD-10 Meaningful Use EHR, PQRS, Value Modifier (VM) Physician Compare Midnight Rule
