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© 2012, Integritas Solu4ons and Rice Consul4ng Services, Inc. 1
Three Success Factors Cri0cal to Developing a ICD-‐10 Tes0ng Strategy
December 20, 2012
Three Success Factors Cri0cal to Developing a ICD-‐10 Tes0ng Strategy
Quick Introduc4ons
• Randy Rice, CTAL – Rice Consul4ng Services – Oklahoma City
• Dexter Oliver – Integritas Solu4ons – Atlanta, GA
© 2012, Integritas Solu4ons and Rice Consul4ng Services, Inc. 2
Three Success Factors Cri0cal to Developing a ICD-‐10 Tes0ng Strategy
• October 1, 2014 the US will Transi4on from Ninth Edi4on of the Interna4onal Classifica4on of Diseases (ICD-‐9) to ICD-‐10
• Transi4on will have major impact on health care informa4on that contains diagnosis and or inpa4ent procedure codes
• Effects Hospitals, Healthcare Prac44oners
• Health insurers, and other third party payers, Clearinghouses
• Hardware and soYware vendors, Billing service providers
• Healthcare oversight Agencies
ICD-‐10 Overview
Making the transi4on to ICD-‐10 is not op4onal!
Benefits Of ICD-‐10
• Improves opera4onal processes by classifying details within the codes to accurately process payments and reimbursements
• Updates terminology and disease classifica4ons to be consistent with the medical and technological advances
• Increases the flexibility for future expansion
• Provides more detailed data to be^er analyze disease pa^erns
• Helps prevent fraudulent claims
© 2012, Integritas Solu4ons and Rice Consul4ng Services, Inc. 3
Three Success Factors Cri0cal to Developing a ICD-‐10 Tes0ng Strategy
What We Learned From Canada
ICD-‐10 Transi0on was a very large work effort significantly underes0mated Lack of planning had a direct impact on there not being enough 0me to adequately test Many vendor system related problems were encountered and workflows were impacted with how physicians worked
1. Leverage Historical Data to establish ICD-‐10 Tes0ng
Objec0ves
2. 3.
ICD-‐10 Test Strategy Success Factor Leveraging what we know about ICD-‐10, it will be important to define and priori4ze the risks to clinical and business process and obtain stakeholder consensus on the extent of tes4ng required to mi4gate risk exposure.
© 2012, Integritas Solu4ons and Rice Consul4ng Services, Inc. 4
Three Success Factors Cri0cal to Developing a ICD-‐10 Tes0ng Strategy
Reduce the likelihood of impacts to High-‐Dollar, High Volume, High Risk scenarios or episodes of care to minimize poten4al financial risk.
Maintain a reliable opera4on of workflows across Clinical Departments, Finance Department and Opera4ons. Examine baseline metrics like # of Physician Queries and response 4me. Coder produc4vity rates, Number of denial\rejects
ICD-‐10 will require more detailed specific informa4on in the medical records from physicians. This requirement could increase the number of RAC audits. HIPAA 5010 transac4ons will need to be tested with sending actual ICD-‐10 data
Minimize Revenue Cycle
Impacts
Minimize Produc0vity impacts for Clinical and
Administra0ve opera0ons
Reduce Risk of
Regulatory Non-‐
compliance
Common Tes4ng Objec4ves Across the Industry
An ICD-‐10 Tes4ng Strategy
• Test strategies describe the “big picture” objec4ves and characteris4cs of the test. – Benefits:
• To avoid designing and performing the wrong test.
• To maximize test effec4veness, efficiency and value.
© 2012, Integritas Solu4ons and Rice Consul4ng Services, Inc. 5
Three Success Factors Cri0cal to Developing a ICD-‐10 Tes0ng Strategy
Once you have the strategy defined, the test plan becomes much easier to
define and is more focused!
3.
2. Iden0fy poten0al problem areas and their effects
to help determine
ICD-‐10 tes0ng approach
1.
ICD-‐10 Test Strategy Success Factor
Execute a Good System Quality Risk Analysis Process
© 2012, Integritas Solu4ons and Rice Consul4ng Services, Inc. 6
Three Success Factors Cri0cal to Developing a ICD-‐10 Tes0ng Strategy
New AMA Study shows CMS underes4mated costs and 4me to implement ICD-‐10.
• A typical Small Prac4ce = $83290 in costs
• A Medium Size Prac4ce = $ 285195 (10 providers)
• A Large prac4ce =$2.7 million (100 providers)
• Hospitals = can expect cost from 3 to $20 million
These cost vary in each organiza4on but may include the cost to implement system upgrades, training and loss of produc4vity for physicians, clinical documenta4on specialists and coders. An increase in coding, billing and payment errors will result in a higher rate of rejec4ons and extend accounts receivables
ICD-‐10 Major Risk Areas
Internal Unit\Integration\System
User Acceptance Testing
• Vendor SoTware & Interface Tes0ng
• Dual Coded Clinical Records
• Computer Assisted Coding Tes0ng
• Compliance Tes0ng
Proposed Tes4ng Approaches
• Dual Coded Transac0ons
• High Risk transac0ons
• ICD-‐10 Coding Accuracy
• Billing Tes0ng
• Compliance Test
© 2012, Integritas Solu4ons and Rice Consul4ng Services, Inc. 7
Three Success Factors Cri0cal to Developing a ICD-‐10 Tes0ng Strategy
Trading Partner Testing End-to-End Testing • Dual Coded Clinical
Records
• High Risk transac0ons
• Clearinghouse Tes0ng
• Payer Mapping Test
• Compliance Tes0ng
Proposed Tes4ng Approaches Cont
• Dual Coded Transac0ons
• High Risk transac0ons
• Pricing tests
• Payer Mapping Test
• Compliance Test
What Frames the ICD-‐10 Test?
• This is a large-‐scale, distributed and integrated test. – Internal and external points of integra4on – There is a major workflow risk
• Having external, contracted coders doesn’t mi4gate the risk!
– ICD-‐10 impacts the data layer in systems • This carries with it an architectural risk.
© 2012, Integritas Solu4ons and Rice Consul4ng Services, Inc. 8
Three Success Factors Cri0cal to Developing a ICD-‐10 Tes0ng Strategy
Producer vs. Customer
• Producer and vendor concerns – Have the soYware changes been implemented correctly?
– Have the data structure changes been implemented correctly?
– Will the changes be ready on 4me?
Producer vs. Customer • Consumer concerns
– Will the updated systems support business processes?
– How do we know what has been impacted by ICD-‐10 changes?
– Will integra4on with internal and external en44es be correct?
– Have business risks been iden4fied and mi4gated?
– Do we have the needed skills to test changes?
– Will the changes be ready on 4me?
© 2012, Integritas Solu4ons and Rice Consul4ng Services, Inc. 9
Three Success Factors Cri0cal to Developing a ICD-‐10 Tes0ng Strategy
Key Point
• If you are in the customer role, you can’t assume the soYware vendor will test sufficiently for your needs.
Why a simple data conversion process and test is not workable.
© 2012, Integritas Solu4ons and Rice Consul4ng Services, Inc. 10
Three Success Factors Cri0cal to Developing a ICD-‐10 Tes0ng Strategy
CRITICAL HOSPITAL METRICS
“You can’t manage it if you can’t measure it.”
MITIGATE YOUR RISKS: Establish Baseline Metrics
© 2012, Integritas Solu4ons and Rice Consul4ng Services, Inc. 11
Three Success Factors Cri0cal to Developing a ICD-‐10 Tes0ng Strategy
1. 2.
3. Think through technologies and facili0es needed to
support tes0ng processes
ICD-‐10 Test Strategy Success Factor
If the overall tes4ng environment needs are understood up-‐front, it will be easier to put the necessary environments in place
Impacted Business Processes
• Pa4ent registra4on • Order entry • Clinical documenta4on process steps and workflow
• Billing • Referrals and authoriza4on • Compliance Management • Coding • Quality repor4ng
© 2012, Integritas Solu4ons and Rice Consul4ng Services, Inc. 12
Three Success Factors Cri0cal to Developing a ICD-‐10 Tes0ng Strategy
Ques4ons to Ask and Answer
• Do we have access to a test environment for ICD-‐10 tes4ng? – If so, is the environment controlled and available?
• Do we have sufficient people for planning and performing ICD-‐10 tes4ng?
• Do we have sufficient processes and tools for ICD-‐10 tes4ng?
• Do we have good subject ma^er expert input to test planning and performance?
Example: Medical Claims Process
© 2012, Integritas Solu4ons and Rice Consul4ng Services, Inc. 13
Three Success Factors Cri0cal to Developing a ICD-‐10 Tes0ng Strategy
Treatment of Pa4ent
Claim submi^ed electronically
Paper-‐based diagnosis form
Claim processing
Pa4ent
Provider or coding service
Provider – Hospital, clinic, etc.
Covered?
Deduc4ble met?
Yes
Yes
EOB
No
No
EOB and check
ICD-‐10 ICD-‐10 ICD-‐10 ICD-‐10
ICD-‐10
ICD-‐10
ICD-‐10
ICD-‐10
Insurance company
Insurance company
Insurance company
ICD-‐10
Office staff
Office staff
EOB and check
Co-‐payment
SAMPLE CLAIMS PROCESS – Scenario 1
Treatment of Pa4ent
Claim submi^ed electronically
Paper-‐based diagnosis form
Claim processing
Pa4ent
Provider or coding service
Provider – Hospital, clinic, etc.
Covered?
Deduc4ble met?
Yes
Yes
EOB
No
No
EOB and check
ICD-‐10 ICD-‐10 ICD-‐10 ICD-‐10
ICD-‐10
ICD-‐10
ICD-‐10
ICD-‐10
Insurance company
Insurance company
Insurance company
ICD-‐10
Office staff
Office staff
EOB and check
Co-‐payment
SAMPLE CLAIMS PROCESS – Scenario 2
© 2012, Integritas Solu4ons and Rice Consul4ng Services, Inc. 14
Three Success Factors Cri0cal to Developing a ICD-‐10 Tes0ng Strategy
Provider Claim submi^ed electronically
Paper-‐based diagnosis form
Provider or coding service
ICD-‐10
Pa4ent
Medicare CMS
EOB
EOB and payment
ICD-‐10
ICD-‐10
ICD-‐10
ICD-‐10
THE END TO END TEST IMPACT
Provider Claim submi^ed electronically
Paper-‐based diagnosis form
Provider or coding service
ICD-‐10
Insurance company “A”
Pa4ent
ICD-‐10
Medicare CMS
Pa4ent
EOB
EOB and payment
EOB and payment
EOB and payment
ICD-‐10
ICD-‐10
ICD-‐10
ICD-‐10
ICD-‐10
ICD-‐10
THE END TO END TEST IMPACT
© 2012, Integritas Solu4ons and Rice Consul4ng Services, Inc. 15
Three Success Factors Cri0cal to Developing a ICD-‐10 Tes0ng Strategy
Provider Claim submi^ed electronically
Paper-‐based diagnosis form
Provider or coding service
ICD-‐10 ICD-‐10
Insurance company “A”
Insurance company “B”
Pa4ent
ICD-‐10
Medicare CMS
ICD-‐10
Pa4ent
Pa4ent
EOB
EOB and payment
EOB and payment
EOB and payment
EOB and payment
EOB and payment
ICD-‐10
ICD-‐10
ICD-‐10
ICD-‐10
ICD-‐10
ICD-‐10
ICD-‐10
ICD-‐10
THE END TO END TEST IMPACT
Provider Claim submi^ed electronically
Paper-‐based diagnosis form
Provider or coding service
ICD-‐10 ICD-‐10
Insurance company “A”
Insurance company “B”
Insurance company “n”
Pa4ent
ICD-‐10
Medicare CMS
ICD-‐10
ICD-‐10
Pa4ent
Pa4ent
Pa4ent
EOB
EOB and payment
EOB and payment
EOB and payment
EOB and payment
EOB and payment
EOB and payment
EOB and payment
ICD-‐10
ICD-‐10
ICD-‐10
ICD-‐10 ICD-‐10
ICD-‐10
ICD-‐10
ICD-‐10
ICD-‐10
ICD-‐10
THE END TO END TEST IMPACT
© 2012, Integritas Solu4ons and Rice Consul4ng Services, Inc. 16
Three Success Factors Cri0cal to Developing a ICD-‐10 Tes0ng Strategy
What’s Needed?
• Iden4fica4on of all interfacing organiza4ons and systems. – HIPAA standards facilitate the data interfaces but do not ensure the correctness of data handling.
• Iden4fica4on of the points of contact in each interfacing en4ty. – Be prepared for delays in exchanging informa4on.
• A plan with schedules and resources clearly defined.
OUR TEST APPROACH
• Our ICD-‐10 test approach is risk-‐based, which means the degree of tes4ng is planned and performed rela4ve to the risk level. – In this view, tes4ng becomes a measure of the extent to which risks have been successfully mi4gated.
• Through our ICD-‐10 tes4ng assessment, we leverage our tools to know where to focus your tes4ng.
• Since most healthcare providers use vendor-‐developed systems, the tes4ng we propose is based on business processes with ICD-‐10 impact. – Regression tes4ng will be needed for cri4cal processes, even those without direct ICD-‐10 impact.
© 2012, Integritas Solu4ons and Rice Consul4ng Services, Inc. 17
Three Success Factors Cri0cal to Developing a ICD-‐10 Tes0ng Strategy
Next Steps
• Download the White Paper at: – h^p://integritassolu4ons.net
• Get management’s a^en4on and support.
• Schedule a consulta4on. – [email protected] – [email protected]
• Stay up to date with ICD-‐10 events. – h^p://www.cms.gov/Medicare/Coding/ICD10/index.html
Ques;ons and Answers
© 2012, Integritas Solu4ons and Rice Consul4ng Services, Inc. 18
Three Success Factors Cri0cal to Developing a ICD-‐10 Tes0ng Strategy
December 20, 2012
Thank You!
