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Pathways to Partnerships | Bridging Connections For Value edifecs confidential 1
Ensuring Revenue Success with a 1-2 PunchStrategies for succeeding in a perfect revenue storm
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 2
Agenda 1. Who is Edifecs?
2. The Perfect Revenue Storm & Success Checklist
3. Solving Real Scenarios
4. Executing Your 1-2 Punch
5. Achieving Value – A Long Term Solution
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 3
Innovator in Healthcare IT
“Customer first innovation model, proven by 20 years of reinvesting into new solutions to meet the demands of the radical
transformation impacting healthcare”
Serving more than 215 million lives through our 350+ customers
Smart Trading
Automate data validation
2006
Compliance
Simplify compliance management
2009
Revenue Integrity
Ensuring revenue integrity
2012
Population Payment
Design and operationalizevalue-based contracts
2015
SpecBuilder
Standardize mappingand simplify testing
1996
Worldwide745+ Employees
LeadersIn Trading and Compliance
MultipleFederal Agencies incl. CMS
Top Health Plans
8/9
Care Providers
100
Blue Plans
25/36
Medicaid Programs
25/52
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 4
What You Don’t Know Can Hurt You!
HCC Coding
Submission Quality
Submission Timeliness
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 5
Perfect Revenue Storm 2016
Submission
Timelin
ess -
2 months l
eft for
2015 data
submiss
ions
HCC Coding - ICD-10 transition &
coding inconsistencies
Submission Quality–
RADV/IVA audits
and coding
comparison
analyses
Submission
Quality-
EDPS/RAPS data
submission for
risk score
calculation
HCC Coding - ICD-10 transition
& coding inconsistencies
Submission
Timeliness
–
ICD-10 support
Marketplace
Medicare Advantage
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 6
Have you performed ICD-10 impact assessment on HCC risk adjustment? Yes, we have full understanding of Impact My existing Risk Adjustment vendor will analyze the data for me No, we have not performed an assessment What’s an HCC?
Polling Question 1
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 7
Checklist – Your Priorities for Success Review volume of ICD10 claims received in Q4. Identify
any volume gaps at the provider level Compare conditions / case-mixes received throughout
the year and prior years Ensure encounters are submitted and reconciled w/
ability to manage exceptions Calculate estimated risk score of members using ICD9+
ICD10 Compare risk scores to previous year to identify +/-
shifts > x% Report discrepancies to identify root cause (claim
volume, ICD9-10 mismatch, encounter exception issues, etc)
Leverage ICD10 granularity to optimize risk scores
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 8
Solving Real Scenarios
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 9
Perfect Revenue Storm – ICD-10
Sample Membership : Regional health plan with a membership of 119k members
3 % of membership have
diagnosis codes which
have a variation in HCC
codes between ICD-9 and
ICD-10
30 % of members with
HCC code variations due
to unspecified code usage
in ICD-10
10 % of HCC code loss is
happening due to
combination codes not
coded properly in ICD-10
~ 1% of HCC risk scores
are lost in pregnancy and
new born conditions
between ICD-9 and ICD-10
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 10
ICD-9 and ICD-10 Diagnosis codes are linked to hierarchical condition categories (HCCs) which have associated risk factors and that drive member risk scores
ICD-9Diag 1 Diag 2 Diag 3 Diag 4
HCC X1 HCC X2 HCC X3
Member level risk score
Risk Adjusted Payments (CMS MA/HIX RA/ACO)
ICD-10
HCC shift can lower or increase risk score
Revenue impact due to change in payments
HCC Shifts Types:HCC in ICD-10 is HigherHCC in ICD-10 is LowerNo HCC in ICD-9 and HCC in ICD-10HCC in ICD-9 and No HCC in ICD-10
Diag 1 Diag 2 Diag 3 Diag 4
HCC X1 HCC X4 No HCC mapping
Member level risk score
Risk Adjusted Payments (CMS MA/HIX RA/ACO)
Revenue Perfect Storm – ICD-10
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 11
Perfect Revenue Storm– Prioritized Exception Management
One health plan managing 500K Marketplace members and 200K Medicare Advantage members
Missed Opportunities
Unable to submit updates/corrections due to issues with internal systems
No discrepancy analysis of what plan considers a risk adjustment diagnosis vs CMS
Missed submission timelines due to delay in prioritizing error corrections
ICD-10 coding errors and potential issues with risk score loss
Rudimentary and unsophisticated processes for exception workflow/correction
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 12
Member with high risk conditions/HCC codes
Member approaching RI Limit or exceeded
Members rejected for missing information
Members with invalid coverages
Member
Claims with HCC eligible diagnoses not submitted to
CMS
Claims with HCC variations in ICD-10
Rejected claims with HCC risk diagnoses
Claims with missing membership information
ClaimsPerfect Revenue Storm– Prioritized Exception Management
WatchRecorded webinarStrategies for succeeding in a perfect revenue storm
Be sure to engage with Edifecs at RISE Annual 2016.
Roundtable discussion: 3:45 – 5:00 PM on Monday 3/21. Gain additional, detailed insight into how intelligently managing the ICD-10 transition and implementing prioritized exception workflows can translate into increased revenue!
Edifecs booth: Connect with Edifecs encounter management, risk adjustment and ICD-10 industry experts and get your questions answered!
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 13
We’ll see you at RISE Annual 2016!
Be sure to engage with Edifecs at RISE Annual 2016. How? Here’s the details:
• Roundtable discussion: 3:45 – 5:00 PM on Monday 3/21. Gain additional, detailed insight into how intelligently managing the ICD-10 transition and implementing prioritized exception workflows can translate into increased revenue!
• Edifecs booth: Connect with Edifecs encounter management, risk adjustment and ICD-10 industry experts and get your questions answered!