Transcript Making the most gains in 2014

ICD-10 The Last Mile
September 2014
Agenda
 It’s just another mandate!
 Organizational Assessment
 Planning and Implementation
 Configuration Reality Check
 Validation and Testing
 Managing the delay
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Background
 John Harbourne, Sr. Director, Business Configuration
and Implantation Services
 Hawaii Medical Service Association
 725,000 members across all line of business
 Commercial and Medicaid/Medicare business
implemented differently
Background
 HMSA Product History
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2000 – Acquired Medicaid plan hosted on QMACS
2002 – Medicare Cost Business (65C+) on QMACS
2005 – Moved Commercial Business to QNXT
2008 – All lines of Business Converted to QNXT
 QNXT Maintenance Routine
 Twice annual upgrades – Spring and Summer
 Current version QNXT 5.01 R8
 In process of implementing QNXT 5.1 R3
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The First Mile: It’s Just another Mandate!
Preparing
CMS Mandate:
ICD-10 codes must be used on all HIPAA
transactions on and after:
October 1,
2013
(Delayed)
October 1,
2014
(Delayed)
October 1,
2015 (?)
Includes outpatient claims based on dates of service, and
inpatient claims based on dates of discharge
Why ICD-10?
 Provides much better data for
 Measuring the quality, safety and efficacy of care
 Payment for quality and outcomes
 Processing claims and other operations
 Reduces need for additional supporting documentation
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Conducting research and clinical trials
Setting health policy
Improving clinical, financial and administrative performance
Preventing and detecting fraud and abuse
Tracking public health and risks
Supports standard electronic health records
Allows facility comparisons
Why ICD-10?
ICD-9 CM
x x x
Category
.x
x
Etiology,
Anatomic site,
Manifestation
• 3-5 digits
• Character 1 is alpha or
numeric
ICD-10 CM
1 2 3
Category
.4
5 6
7
Added code
Etiology,
Anatomic site, for obstetrics,
injuries and
Severity
external causes
of injury
• 3-7 digits
• Character 1 is alpha
• Excludes letter U
The Next Mile: Organizational
Assessment
Initial Assessment
 Opportunities and challenges
 Scope and complexity are significant
 Coded data is more widely used than when US last transitioned
to ICD-9
 Use of EDI transactions
 Automated coding technologies that will revolutionize the
coding process
 Large internal resource effort
 More than providers will be impacted
The Long Mile: Planning and
Implementation
Project Leadership
Executive Sponsor:
Project Executive:
Business Owner:
Executive VP Ops
Senior VP Claims Admin
VP Medical Management
Steering Committee
Project Executive
Health Services SVP
Chief Information Officer SVP
Gov’t Program SVP
Project Organization
Key Business Teams
Configuration
Claims Administration
Finance
Health Services
Bus. Intelligence
Info. Systems
Provider Relations
Gov’t Programs
Business Program/Project Manager
IS Program/Project Manager
Business Test Coordinator
IS Test Manager
Scope of Effort
 IS system remediation
 44 applications
 QNXT configuration
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3 lines of business
 Back-end reporting
 Claims extracts (in/out
bound)
 DRG renovation
 ICD-9  ICD-10
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Mapping and Validation
 Policy Conversion
 Medical and Payment
 BCBSA Requirements
 FEP
 BlueCard
 Communications
 Business associates
 Vendors
 Third parties
 HMSA staff training
 Coders
 Analysts
 General education
Out of Scope
 Systems not containing ICD-9
 Department specific/owned (BAU)
 Procedures
 Workflows
 Applications
 Communication with other stakeholders
 Employer groups
 Members
 State Legislature
 Changes impacting provider
 Contracts
 Reimbursement strategies
 Coder training
Remediation Strategy
Staged Approach
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Convert all systems that use ICD-9 to work with ICD-10
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Replace, upgrade or remediate
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Maintain ICD-10 to ICD-9 mapping for data analysis and
research
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Complete transition to full ICD-10 environment by
compliance date
Remediation Strategy
Staged Approach
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Convert current policies ICD-9  ICD-10
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Reimbursement mapping
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Validate CMS’ GEM and customize as needed
Configure QNXT to use ICD-10
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Prioritize edits by highest volume or greatest business value
Maintain ICD-9 edits as needed for transition
The Mile After: Configuration Reality
Check
Reality Check
 ICD-10 diagnosis configuration for 3 business lines
 Initial estimated manual
effort to prep, build &
unit test
 46,000 hours
Benefits:
35,701
QNXT
Renovation Effort
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Contract
Terms:
24,983
Total:
60,684
Time to Innovate
 Large renovation effort required an alternative approach
Internally
Developed Solution
SQL Scripts
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Quick process
Load GEM
Load custom
Require IS support
Trizetto CSSB
Not scalable
Small Dev. Impact
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Lengthy process
UI and database
User administered
Trizetto CSSB
Dev. Maintenance
Saleable
Heavy Dev. impact
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Externally
Developed Solution
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Lengthy process
UI and database
User administered
Trizetto CSSB
Dev. Maintenance
Saleable
Small Dev. Impact
Mutual Collaboration
Share Define
Ideas Req.
Beta
Test
First
Deploy
Q4
Q1
Q3 – Q4
Q1
2011
2012
2012
2013
 Entered into a Joint Development effort with Trizetto
 Core Development Team:
 HMSA Resources – 2 configuration & 2 IT
 Trizetto Resources – 2 developers/designers
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ICD Configuration Tool
ICD Configuration Tool
 What is the ICD-10 Configuration Tool
 Automates the process of loading previously mapped ICD-10
codes for corresponding ICD-9 codes into the QNXT database
 How are the maps generated?
 The ICD map to be loaded is created using an external mapping
tool (e.g. 3M CTT, HLI, HCL, Edifecs) or by using the GEMs
 Which environments can I use this for?
 The tool can be linked to multiple QNXT environments.
ICD Configuration Tool
 Updates Diagnosis/Procedure code configurations based
on ICD-9 to ICD-10 maps for five modules
 Accepts ICD maps from any external mapping tool
 1:1 or 1: Many Relationships
 Manages User Roles and Access Management
 Utilizes User Workflow
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Users Selects an Environment
User Submits Mapping Configurations for specified entities
User Approves/Rejects and Applies Configurations
User Reviews and/or Exports Audit Reports
ICD Configuration Tool
 Apply Configuration to multiple environments
(Development, Test, or Production)
 Ability to search QNXT database for entities to
configure
 Ability to select single or multiple entities for
configuration
 Ability to update single ICD codes and ICD code
ranges
High Level Configuration Process
Mapping UI
ICD Map
Target Environments
 Development
 Test
 Production
QNXT
Config
Tool
Tool
Mapping
Engine
Target
QNXT
Environment
High Level Entity Configuration
Current Configuration
Benefit
Name
ICD 9 Code
Ben 1
………..
Ben 2
646.31
Ben 2
646.33
Ben 2
646.4
Ben 2
646.41
Ben 3
……..
Map File
ICD9_Codes
ICD10_Codes
646.3
646.31
646.31
646.31
646.33
646.33
646.33
646.4
646.41
646.41
646.41
646.42
646.42
646.42
646.43
646.43
646.43
..
646.93
O26.20
O26.21
O26.22
O26.23
O26.21
O26.22
O26.876
O26.829
O26.821
O26.822
O26.823
O26.821
O26.822
O26.823
O26.821
O26.822
O26.823
..
O99.89
QNXT Config Tool
New Configuration
Benefit
Name
ICD 9
Code
ICD 10
Code
Ben 1
……
Ben 2
646.31
O26.21 –
O26.23
Ben 2
646.33
O26.21
Ben 2
646.4
O26.829
Ben 2
646.41
O26.822 –
O26.823
Ben 3
……..
Data Integrity
 Tool utilizes its own database for maintaining
user roles, user management, audit trail, etc
 Changes only applied to Plandata database after
user approval
 The configuration tool updates existing entities
by adding mapped ICD-10 codes but does not
remove existing ICD-9 codes
 The initial ICD-9 to ICD-10 map can be applied
to any other QNXT environment.
User Roles
Home Screen
User Workflow
Select Environment Select entities
Configure &
Submit
Approve/
Reject
Apply
Audit
User Workflow
Select Environment Select entities
Configure &
Submit
Approve/
Reject
Apply
Audit
User Workflow
Select Environment Select entities
Configure &
Submit
Approve/
Reject
Apply
Audit
User Workflow
Select Environment Select entities
Configure &
Submit
Approve/
Reject
Apply
Audit
User Workflow
Select Environment Select entities
Configure &
Submit
Approve/
Reject
Apply
Audit
 Mapping Engine
applies the ICD9ICD10 mapping for the
selected entities in the
QNXT Plandata
database
Failure
Success
Audit
 Success and Failure
details are logged in
the Audit report
User Workflow
Select Environment Select entities
Configure &
Submit
Approve/
Reject
Apply
Audit
The Last Mile: Validation and Testing
Deployment and Test Organization
 Configuration Team
 One business analyst
 One builder
 IS Test Manager
 Manages promotions and test system processing
 Test Team Coordinator
 Manages business users and case validation
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Testing Strategy
 Phased approach to testing
 Baseline: ICD-9 and ICD-10 can coexist
 Phase 1: ICD-10 neutrality in benefit selection and
process
 Phase 2: EDI front-end
 Phase 3: Financial liability compare and wrap-up
 Phase 4: Provider readiness testing
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Testing: Phase 1
 Phase 1: ICD-10 Configuration Test
 Purpose: Compare production claims to ICD-10 test data, with
objective of determining payment and work neutrality
 Ran same scenarios, cases, and data from initial ICD-9 test
 Business units to provide additional needs and policy criteria
 Business units to identify critical processes for testing
 Test was successful but pointed out that some maps updating
 Custom testing tool developed to assist with the comparison
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Testing: Phase 2
 Phase 2: EDI front-end (The Pivot Date)
 Purpose: Ensure EDI front-end rules were functioning properly,
with objective of validating EDI acceptance policy
 Rules coded into EDI
 Overlapping pivot date
 ICD-9 prior to ICD-10 date
 When do we split or not
 Turn on and off and regression
 Many issues were found during the EDI test
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Testing: Phase 3
 Phase 3: Financial Liability Compare
 Purpose: Complete end-to-end test with objective of ensuring
processing was consistent with production
 Underwriting and financial to run financial compares – heavy focus
on payment neutrality
 Continue anything carry over from phase 2
 Any remaining testing that business wanted to conduct
 Needed 5.1 R3 for DRG grouper
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Testing: Provider Readiness
 Phase 4: Provider readiness
 Purpose: Ensure high volume/impact providers can successfully
submit claim file
 Work with local provider and facilities to test their updated files
 Feedback to providers to ensure they do not drop to paper
 Time to review how providers mapped
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Value Proposition
 Allows a full renovation for testing purposes
 Can renovate multiple times as needed
 No need to renovate in prod & copy back to test
 Renovations done in bulk via maps
 GEMS map can be applied to all config with little effort
 Tool can reconcile existing ICD-10 config when changes are made
to original map (Fresh vs. Reconcile)
 Renovation time manageable: 2-3 weeks in duration
 Compared to thousands of hours
 Automated QA using tool reports & queries
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Value Proposition
 Renovated multiple times over past 2 years:
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Q4 2012 Test & Prod
Removed from production due to changing maps
2013 Test 2x’s
2014 Test 1x
Target Prod build Q3 2014
Maintenance through 2015
 Testing early revealed mistakes
 Easy to remove ICD-10 configuration & renovate again
 Full renovation allows for term compare
 More confident in ICD-10 readiness
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One More Mile: Managing another delay
Impact of Delay
 This delay was more disruptive than the first
 Still… renovation will not be the problem
 Introduced risk and new opportunities
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Risk: Overall loss of momentum – internal and external
Risk: Possible non-compliant development occurring
Risk: Provider focus and testing will fall behind schedule
Risk: Increases overall cost of project
Opportunity: Relook at our test strategy
Opportunity: Relook at liability comparison tools
Opportunity: Upgrade iCES or other systems
Opportunity: Improve provider test environment
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Next Steps
 Complete QNXT 5.1R3 upgrade
 Finish near-complete activities and pause
 Update existing and build remaining test cases
 Generate updated test data for new cases and regression
 Execute and complete final end-to-end ICD-10 testing
 Prepare for provider readiness testing
 Complete Claim Test Pro Implementation
 ICD-10 regression test
 Financial liability compare
 Assess iCES upgrade to version 5.x
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Questions
?
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Contact Information
 Hawaii Medical Service Association (HMSA)
 John Harbourne
 Sr. Director, Business Configuration and Implementation
Services
 [email protected]
 808-948-5401
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Workshop Survey
We would like to extend you an opportunity
to provide candid feedback.
During the workshop you should have received an e-mail
notification for you to take an on-line survey.
If you could take a few minutes to complete at this time ,
we would greatly value your feedback. For your convenience,
the survey will be available throughout the remainder of the conference
should you not be able to complete immediately.
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