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icd-10 is an enterprise wide challenge for health plans and health care providers. Our firm has performed ICD-10 work for companies across the U.S.
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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
http://www.noworldborders.com 1
More About Ushttp://www.noworldborders.com
Ten years of success with payers, providers, pharmaceutical and medical device companies
Success stories More about our ICD-10 approach Nationally recognized experts
– HIPAA 5010 and ICD-10– Meaningful Use– Medicare Advantage Quality Measures (HEDIS, Star
Ratings, CMS VBP)– Process improvement– Claims systems
Private equity backed
2http://www.noworldborders.com
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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http://www.noworldborders.com
Unique Challenge of ICD-10
Three Constraints, Single Compliance Date
4
Compliance Iteration & InnovationVs.
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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
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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
For a complete slide presentation,
please contact No World Borders
http://www.noworldborders.com6
Risk Mitigation
Risk identification & trigger events
Risk Mitigation Planning
Examples of the 5 dimensions, 25 Risk
Areas
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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)
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ICD-10 Key Risks (page 1 of 3)
Excerpts from 25 Risk Assessment Areas
9
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
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ICD-10 Key Risks (page 2 of 3)
Excerpts from f 25 Risk Assessment Areas
10
Risk Risk Trigger Event Remediation / Mitigation
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
For a complete slide presentation,
please contact No World Borders
http://www.noworldborders.com
ICD-10 Key Risks (page 3 of 3)
Excerpts from 25 Risk Assessment Areas
11
Risk Risk Trigger Event Remediation / Mitigation
• 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
For a complete slide presentation,
please contact No World Borders
http://www.noworldborders.com
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
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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
13
For a complete slide presentation,
please contact No World Borders
http://www.noworldborders.com
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
14
For a complete slide presentation,
please contact No World Borders
http://www.noworldborders.com
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.
15
For a complete slide presentation,
please contact No World Borders
http://www.noworldborders.com
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
16
For a complete slide presentation,
please contact No World Borders
http://www.noworldborders.com
Next Steps
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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
18
For a complete slide presentation,
please contact No World Borders
http://www.noworldborders.com
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
19
For a complete slide presentation,
please contact No World Borders
http://www.noworldborders.com
ICD-10 Example Impact Assessment Functional Areas with the Most Risk
20
For a complete slide presentation,
please contact No World Borders
http://www.noworldborders.com
Risk Mitigation: Clearly Identify Roles for Payor, Provider Work Teams for ICD-10
21
Risky thinking: “I need a good ICD-10 project manager….”
Comment: “Yes, but there are other organizational competencies needed…”
See http://slidesha.re/icd10orgstrat
For a complete slide presentation,
please contact No World Borders
http://www.noworldborders.com
Provider Specific Factors for ICD-10(Excerpt from Assessment)
For a complete slide presentation,
please contact No World Borders
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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
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What’s next?
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Discovery & Remediation Tools:•COBOL•.NET•Java
9 to 10 Frameworks:•Vocabulary •Concepts•Consortiums
Testing:•Leverage 5010 / ICD-10•End to end
For a complete slide presentation,
please contact No World Borders
http://www.noworldborders.com25
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
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Mike ArrigoManaging Partner, No World
949-335-5580 x1001Recorded webinar on BCP and ICD-10
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