Presented byJoan Kossow

Data Compliance Manager

The Changing Face of Claims Processing &

Overview

• ICD-10– SSI’s approach– What’s

changing?– Provider’s

responsibilities

• Next Steps

ICD-10 Compliance

ICD-10

• Transition to ICD-10 codes is 20 years in the making

• There will be no transition period, the initiative is date driven – 10/1/14

• Comprehensive testing models will change the “face” of testing

• ICD-10 initiative is a “value-based” proposition for the industry

• Workman’s Compensation – not all will transition to ICD-10

SSI ICD-10 Project• SSI’s Core Team formed in 2009

– Subject Matter Experts Cross Multiple Departments

• Cross-Product Design Team formed 2010 – Focus on Consistency– EDI payer acceptance rates– NO CROSSWALKS

• Industry Advocacy– Committee involvement with governmental and non-

governmental agencies, AAHAM, WEDI, HIMSS, HFMA, HBMA, AHIMA, etc.

• ICD-10 information in software i.e., product report cards, FAQ’s, webcasts….and more

ICD-10

• Project analysis and timelines• Product updates on schedule• Internal and external testing• Training internal and external• Collaborations established

– Governmental and non-Governmental Agencies

• HIMSS/WEDI ICD-10 committees • HIMSS ICD-10 Playbook • CORE certified Phase I & II for Eligibility and

Claims Status for Operating Rules

ICD-10 Testing Elements

• Performance Testing• Usability Considerations• Software Quality

Goals/Checkpoints• Ensuring Backward

Compatibility• Minimize “Day 1”

Impacts – Software Apps

• Implementation Procedures – Software Apps

• Outside the Box Testing

ICD-10 • R&D Software developers testing their “code”• Integrated Testing – All software changes tested

together to ensure all works “as designed”• System Testing – Testing software

implementation process• Beta Testing – Software delivered to customers

to test in own environment• General release – providers to test in their own

test environments.• Test systems for ICD-10 a necessity!

Provider Considerations

• Usability – Volume of New Codes• Productivity – will decline initially, until

comfortable with ICD-10 coding• Payers – How they will approach testing?• ICD-9 & ICD-10 Concurrently – will your

vendor/payer be able to support both versions after 10/1/14

• New Scenarios for Testing (date-based, syntax/content, or medical based scenario testing) Out of the box!!!

Provider Considerations

• Pre-requisite Release/Version for ICD-10 Ready Software

• Remember, ICD-10 affects any software that currently utilizes ICD-9, includes Electronic Health Records systems

• Project timelines for internal software integration• Documentation – software updates• Training for ICD-10 Software enhancements• Software integrated testing with each vendor

● Payer Matrix

● Payer Testing Process● Tracking Testing Status● Go-Live 10/1/2014

● Post Go-Live Monitoring

SSI EDI Clearinghouse Payer Testing

Plan Ahead

●Clearinghouse capabilities include the ability to continue to submit ICD-9 transactions post 10/1/2014

●Payers must continue to accept re-bills with ICD-9 codes

●With ICD-10, don’t expect clearinghouses to crosswalk ICD-9 claims if Provider’s systems are not ready or capable of generating transactions with ICD-10 codes

●Documentation is key with coding ICD-10. Medical records must be used for correct coding. Crosswalks inaccuracies have been identified and abandoned by many clearinghouses, payers and other organizations

●Plan ahead, if you know your systems are not going to be ready for ICD-10, internal decisions should be made now to define alternative steps to ensure no interruption in billing occurs

Post Go-Live

●Monitor your systems and reports

●Data analytics is your best friend!

●835s should always be monitored. Patient accounting system postings, payments and adjustments, of the adjudication of the claim should be included in your activities

●Coordinate activities throughout your organization with Medical Records, Contracts Management, etc.

Post Go-Live

●ICD-10 is an opportunity for increased reimbursements based on greater specificity of services provided

●Ensure that your payer contracts demonstrate greater revenue potential

●Data analysis will provide information crucial to your organizations profitability and afford information to make negotiated modifications with your payers in management of your contracts

Post Go-Live

●Verify that every aspect of your systems are functioning correctly. Identify and address issues quickly

●Keep track of post go-live issues and resolutions. They may be beneficial lessons learned for not only your organization, but others in the industry

●Communicate and Collaborate with trading partners

●Ultimate goal – successful transition with minimal disruption

Contingency Planning

• Obtain advanced approval for loans for your organization in case of impacts to your revenue stream

• Develop contingency plans in case your systems and software are not update timely for compliance by 10/1/14

• Validation of ICD-9 to 10 remittances to assist in your historical and future revenue streams

• Assist Physicians by developing guidance for appropriate documentation associated with ICD-10 coding

Contingency Planning

• Ensure that plans incorporated internal resources pre and post implementation needs

• Payers are developing new testing initiatives for ICD-10. If your facility is not selected as a BETA test site, use the time to concentrate on readiness internally

• Determine what type of testing is needed internally with updated ICD-10 integrated systems to ensure that the appropriate information is integrated in the financial systems

Challenges

• Not all system errors may be related to ICD-10• Remember that many systems are being

updated and you must do your due diligence in identifying were the issue actually resides and in which product

• Infrastructure capabilities, protocols and procedures must be updated to accommodate ICD-10 from Eligibility to denial management.

• Continue your ICD-10 project teams well past the implementation date of 10/1/14

Get Ready! Time is Short!!

Thank you!