HIPAA 5010Impact Assessment & Readiness

WEDI Fall Conference - November 8-11, 2010

Are you riding the waves or is there going to be a wipeout?

Speakers

• Rob Fisher, Director, Payer Services, RelayHealth

• Craig Penrose, PMP, Senior Director, Assessment, Procurement and Consulting, FlexTech

• Barry Reeher, Senior Technical Consultant, FlexTech

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Did you know? The transition to 5010 involves 5000 data element changes.

Agenda

• How will 5010 make life better?

• Most common issues facing health plansregarding 5010

• Best implementation practices – 5010

• How is FlexTech helping health plans succeed with their projects?

• How is RelayHealth’s Payer Services helping payers reach their compliance goals?

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• With more precise clinical documentation, payers can reduce medical loss ratios.

• Payers will be able to auto-adjudicate more claims. • Prevent inappropriate payments (subrogation, fraud and

abuse).• Locating missing information will be easier, reducing

time delays and costs.• Replacing generic descriptions with specific descriptions

streamlines the process.

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How will 5010 make life better? The conversion to 5010 will make information exchange simpler and more straightforward, improving all aspects of healthcare business, and driving payers to improve business strategy.

5010 / ICD-10 Timeline

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Where is your org in the readiness timeline?

• Many payers have multiple vendor and internally supported systems and applications.

• Retain all inbound 5010 data for outbound processing (backfilling).

• Coordination of multiple software system upgrades to compliant versions.

• Assessment of remediation requirements for interfaces to software systems without compliant version specifications.

• Payers will likely have to support transactions in both formats for a period of time as an accommodation.6

Most common issues facing health plans regarding 5010These conversion projects come at a time of extreme financial and resource challenges. The transition carries direct financial risk because it is related to billing and revenue management.

Best implementation practices – 5010• Map 5010 to 4010 at the gateway.• Implement system upgrades and remediate the

database changes.• Remediate 5010 from point of reception to backend,

one component at a time. • Perform parallel testing from point of reception to

backend, one component at a time.• Implement small early adopters to facilitate functional

testing and overall operational testing.• Implement a single (large) early adopter.• Stage implementations with completion dates being

on or before 01/01/2012.

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Best Practice – 5010 Project Deliverables

• Organizational Readiness Gap Analysis• Organizational structure, business partners, past HIPAA

experiences (governance, lessons learned), business change methods and experience, strategic plans, budgets, and ICD-10 knowledge

• Business Process Gap Analysis• Identify business process gaps, risks, new capabilities

required, and key business rule changes

• IT Systems Gap Analysis• Identify required system and data changes, 5010

impacts, key vendor readiness, risk, and linkage of automation and business organization

• Cost Assessment• Based on cost project factors

• High Level Roadmap for Compliance8

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• Proven Methodology• Proven Tools• Repeatable & Predictable

Results• History of Experience• Objectivity and Focus• Bandwidth to Deliver

A Third Party Advantage

How is FlexTech helping healthplans succeed with their projects?

Why health plans turn to a third party resource

Assessment Methodology

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Assessment Methodology Work Streams

Organizational Readiness

Business Process Impact

IT Systems Impact

Data Gathering Data GatheringData Gathering

Evaluation Gap Analysis

Evaluation Gap Analysis

Evaluation Gap Analysis

Recommendations/Roadmap

Assessment Management Ph

ases

Assessment Area Tool Kits

Overall ImpactAssessmentManagement

• Assessment Work Plan Template• Downstream impacts for data and business• Existing and future projects

Data GatheringPhase

• Application Interview Functional Inventory• Stakeholder Responsibilities Matrix• 5010 Charter Template• 5010 Scope Template• 5010 Business Requirements Template• Business Process Inventory• Interface Inventory• Data Flow Inventory

Evaluation Gap Analysis Phase

• Application Inventory Interview Crosswalk• CMS Mapping of 4010A1 to 5010• X12 and Changes Guides• Vendor and Product Cross-Reference and Analysis Tool • 5010 and ICD-10 Transaction Conceptual Views and Flow Guide

Recommendations/Roadmap Phase

• Profile and Readiness Checklist• Final Presentation and Written Report Templates

Assessment Toolkit

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How is RelayHealth Payer Services helping payers reach their compliance goals?

“We selected RelayHealth for our 5010 solution. Their innovative Payor Connectivity Services (PCS) provides much more value than a traditional EDI trans- action clearinghouse with the flexibility to scale with our changing requirements.”

- PCS Customer

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PCS 5010 & Beyond Program

• HIPAA-compliant Intelligent Gateway• Scalable Software as a Service (SaaS) platform• Modular design which enables expansion of

applications and functionality• Payor-customizable pre-adjudication validation and

routing• Ability for submitters to correct claims prior to

submission• 4010-to-5010 conversion service• 5010 testing tool• ICD-9 to ICD-10 compliance• Payor and provider self-service web reporting• Complimentary implementation services

RelayHealth’s PCS 5010 and Beyond Program includes:

fasttrack5010@relayhealth.com / www.fasttrack5010.com

Preparing our customers to think beyond 5010

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Nine clients have contracted for PCS implementation projects scheduled to go live by December 2010.

“By choosing RelayHealth PCS, complexity is reduced, which will bring further efficiencies to our processes, and help to reduce costs. PCS provides alternatives for how we conduct transactions with different partners and the information we share.” - PCS Customer

Payor Connectivity Services

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With a modular design, PCS can be implemented so you can add future functionality to scale with your changing requirements.

Payor Connectivity Services5010 HIPAA Gateway

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Built to handle health plan needs such as HIPAA 5010, clinical data transactions, and pre-adjudication processing, PCS is an end-to-end solution that reduces the gap between providers and payers.

• Support standard and advanced communication protocols as defined in CORE Phase II

• RelayHealth translates incoming data into any format your systems require

• Ability to split and route files to you based on various criteria

PCS 5010 HIPAA GatewayEDI validation

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• Ensures transactions meet HIPAA requirements

• Flexibility to add health plan specific business rules

• Rejects transactions based on business rules

• Easily create companion guides for your provider community with the click of a button

PCS 5010 HIPAA GatewayReporting & analytics

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• Visibility into reject data and trends

• Grading of submitters with common metrics

• Trading partner reports

• Channels problem areas to management

• Audit reports• Create alerts based on

triggered events

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5010 Certification Program

Education Data Generation

For You

For YourTradingPartners

Migration Solution

5010 - 4010Conversion Utilities

5010 TestEnvironment

5010 Certification

Trading Partner Testing Program

www.fasttrack5010.com www.testtrack5010.com

Questions?

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>What has your 5010 experience been? >What’s your biggest concern?>What’s next?

• Rob FisherRob.Fisher@RelayHealth.com (770) 237-7719

• Andy FoxAndrew.Fox@RelayHealth.com(610) 430-3690

• Craig Penrosecpenrose@FlexTech.com 734-424-6898

• Barry Reeherbreeher@FlexTech.com 21

Contacts for Information

www.FastTrack5010.com

www.FlexTech.com

What’s your strategy?• Pragmatists – Basic compliance. Basic coding, EDI transactions

implementation, updating of governmental reporting, and required core administrative and revenue cycle process updates. Wrap-around solutions such as EDI and code set cross-walks to minimize cost and impact.

• Collaborators – More than basic compliance. Remediation of internal reporting and implementation of advanced analytics and payment monitoring to leverage the data obtained through ICD-10 coding. Mid-sized plans may collaborate to share the ICD-10 remediation cost.

• Innovators – Leverage HIPAA 5010/ICD-10 compliance. Focus on strategic value through transforming HCM, contracting and business acquisition processes, advanced training, and outcome management. These orgs will see this as an opportunity to develop new business partnerships and business models.

• Opt out of ICD-10 – Some orgs will try to avoid remediation but there is no option to opt out. 22

Best implementation practices – ICD-10• Develop/purchase a bi-directional Equivalency

mapping.• Used only when a valid equivalent code exists

• Develop/purchase a crosswalk service.• Note that you may need to vary the outcome to accommodate

differences in provider contracts and benefits plans

• Develop new versions of all ICD dependent reports and analysis using the Equivalent or crosswalked ICD-10 codes.

• Compare the results to the ICD-9 versions and address differences through modification of crosswalk, contracting or benefit plan configuration.

• Develop ICD-10 versions of contract terms and benefit terms allowing adjudication to adjudicate historical run out claims using ICD-9 and new claims using ICD-10.

• In a test environment convert paid claims ICD-9 to ICD-10 and adjudicate. compare results and address.

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