HIPAA 4010A1 to 5010 Migration:Rapid Compliance with a

Step Up/Step Down Approach

About Perficient

Perficient is a leading information technology consulting firm serving clients throughout North America.

We help clients implement business-driven technology solutions that integrate business processes, improve worker productivity, increase customer loyalty and create a more agile enterprise to better respond to new business opportunities.

View a Recording of this Webinar and others at Perficient.com/Webinars

PRFT Profile

• Founded in 1997

• Public, NASDAQ: PRFT

• 2009 Revenue of $188 million

• 18 major market locations throughout North America• Austin, Chicago, Cincinnati, Cleveland, Columbus, Dallas,

Denver, Detroit, Fairfax, Houston, Indianapolis, Minneapolis, New Orleans, Philadelphia, San Francisco, San Jose, St. Louis and Toronto

• 1,400+ colleagues

• Dedicated solution practices

• ~450 enterprise clients (2009) and 85% repeat business rate

• Alliance partnerships with major technology vendors

• Multiple vendor/industry technology and growth awards

Perficient brings deep solutions expertise and offers a complete set of flexible services to help clients implement business-driven IT solutions

Our Solutions Expertise & Services

Business-Driven Solutions• Enterprise Portals• SOA and Business Process

Management• Business Intelligence• User-Centered Custom Applications• CRM Solutions• Enterprise Performance

Management• Customer Self-Service• eCommerce & Product Information

Management• Enterprise Content Management• Industry-Specific Solutions• Mobile Technology• Security Assessments

Perficient Services End-to-End Solution Delivery IT Strategic Consulting IT Architecture Planning Business Process & Workflow

Consulting Usability and UI Consulting Custom Application Development Offshore Development Package Selection, Implementation

and Integration Architecture & Application Migrations Education

Our Speaker

Martin Sizemore• Enterprise Architect with specialized skills in Enterprise

Application Integration (EAI) and Service Oriented Architecture (SOA).

• Martin has been a consultant and trusted advisor to CEOs, COOs, CIOs and senior managers for global multi-national companies and healthcare organizations.

• His deep industry experience as a consultant in manufacturing, healthcare and financial services industries has provided him with a broad knowledge of IBM hardware and software offerings with numerous certifications and recognitions from IBM including On-Demand Computing and SOA Advisor.

• He is experienced with Microsoft general software products and architecture, including SharePoint and SQL Server and has worked closely with Microsoft architects on healthcare products including their healthcare CRM, Amalga, and HealthVault offerings.

• Define challenges facing organizations with a 4010A1 to 5010 Migration

• Examine Choices for a Solution• Review the Edifecs Step Up/Step Down Solution

– How this approach addresses the challenges– Pros and Cons

• Next Steps

Today’s Agenda

• The timelines depicted above are illustrative only. The size of the organization and the level of impact would determine more realistic timelines

Strategy and Assessment

Design & Build

Internal Testing

External TestingConversion (Dual-Mode)

Training and Outreach

2010 2011 2012 2013

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Program Management

We are here

5010 Final Compliance ICD-10Compliance

L1 L212/31/2010 12/31/2011 01/01/2012

10/01/2013

Recommended Tasks and Timelines

• Regulatory deadline pressures• Competing with large IT projects

– EMR implementations, claims processing modernization• Lack of experienced professionals with EDI X12 experience• Having 4010A1 and new 5010 transactions match for billing

and A/R– Audit risk from government agencies

• Waiting on software application vendors for ICD-10 upgrades– Many delayed until 2012 – Will need extensive testing

Challenges

Providing options for 5010 Compliance

While each option has pros and cons, many organizations are exploring Step-Up/Step-Down solutions to mitigate risk.

Step Up / Step Down Solution

Remediation

Complete Replacement of Systems

1

2

3

Solution Choices

Our Solution

Subject Matter Expertise• Business processes• HL7 transactions• Trading partners Toolset to automate 5010 processing • Reduces manual effort• Reduces testing effort• Improves speed to implement

Tailored Approach• Assessment of current state, gap

analysis• 4010, 5010 parallel processing• Best practices

Client Tailore

d Appro

ach

Toolset to

automate

5010 proces

sing

Subject

Matter

Expertise

Roll-out with Step Up/Step Down

ICD-10 Full Implementation

Next Generation Healthcare Analytics

•Edifecs5010™ Step-Up/Step-Down Solution–Simple Translation Capabilities–Enterprise Capabilities

•Edifecs5010™ Testing Solution–Edifecs SpecBuilder–Edifecs Ramp Management–Edifecs Transaction Management–Edifecs5010™ Compliance Online

•Edifecs Trained Consulting Services from Perficient–World-class service professionals who are deeply conversant with HIPAA 5010 and trained in the latest technologies.

Perficient’s Edifecs Partnership

Requirements• Accept inbound 5010 transactions and

convert to 4010A1• Transaction Enrichment• Full validation required for transactions• View all transactions for ongoing visibility

and auditing needs• Dual-use capabilities (accept both 4010A1

and 5010 transactions)• Trading partner management capabilities

Solution Components• Pre-built 4010A1-5010 maps

• Edifecs SpecBuilder

• Edifecs XEngine Translator

• Consulting Services

Requirements• No need to validate transactions• Need short-term solution for

processing both 4010A1 and 5010 transactions

Translation

Solution Components• Pre-built 4010A1-5010 maps

• Edifecs SpecBuilder

• Edifecs XEngine Translator

• Edifecs Transaction Management

• Edifecs Trading Partner Management

• Consulting Services

Achieving HIPAA Compliance

FoundationVersion

StandardVersion

•Testing will account for 70% of HIPAA 5010 implementation costs (Gartner)

•Building test data represents a significant portion of overall testing costs

•Manual tasks to create and maintain test data drive up costs and decrease efficiency

Test P

lanning

Data G

enera

tion

Unit and Sys

tem Te

sting

Functiona

l Tes

ting

Test S

tatist

ics an

d Reportin

g0

2000400060008000

100001200014000

Hours

Hours By Phase of Testing

Source: Edifecs Customer

Testing Challenges

Requirements• Convert 4010A1 test files to 5010• Test companion guides• Test SNIP edits• Test acknowledgment generation• Test file splitting• Test Data creation and management

5010 Level 1 Testing (Internal)

5010 Level 2 Testing (External)Requirements• Trading Partner Management• External Transaction Testing• Complete front-end testing• Migration Dashboard/Reporting• Test linking inbound and outbound

transactions

• SpecBuilder- Publish Guidelines

• XEngine- Validation

• Ramp Management- Easily onboard and test with Trading

Partners

• Transaction Management- Maintain Visibility- Manage Trading Partners

• SpecBuilder- Create and Test Guide Lines- Analyze Results

• XEngine- Validation

• Test Management- Create and manage test data

• Ramp Management- Test files

Solution Components

Solution Components

HIPAA Compliance Testing Solution

Process Automated Process Time SavingsCommunicating engagement material • Bulk email invitation

• Step-by-step enrollment process • Build surveys

• Simple or Complex• Conditional questions

• Trading Partner Agreement

From 2 hours to 15 min

Communicate specifications Library with important documents • Private or public

From 45m+ to 0 min

Communicate reference materials Library with important documents • Private or public

From 45m+ to 0 min

Testing• Compliance testing (syntactical

testing)• Payer specific testing• Error correction process

Self-services environment• Web-based with 7x24 access to secured self-testing

facility• Define program workflow• Set up task dependencies• Automatic error notification• Exact Location of errors

From 13h+ to 0 min

Create community progress report • Dashboard screens• Schedule reports• Export reports

From 60 min to 20 min

Total trading partner onboarding time reduced from 17+ hours to 35 minutes28% of survey respondents have over 500 Trading Partners to onboard

Case Study: External Testing

835 Process

837 Process

Stanford Hospital

Mayo Clinic

Clearinghouse

Stanford Hospital

Mayo Clinic

Validation Translation Batching Routing

Splitting Routing Translation Validation

Adjudication System A

(accepts 4010 only)

Adjudication System B

(accepts 5010 only)

System A (Generates 4010 Remittance

Advice)

System B(Generates 5010

Remittance Advice)

Web

/ FT

PW

eb /

FTP

4010 batch for Sys A and Sys B

5010 batch for Sys A and Sys B

4010 Claims batch from Stanford & Mayo

combined

5010 Claims batch from Stanford & Mayo combined

4010 Remittance batch for Stanford & Mayo

5010 Remittance batch for Stanford & Mayo

Clearinghouse

4010 batch of Remit Advices

5010 batch of Remit Advices

• Lossless Translation • End-to-end view of transaction flow

Business Process Flow

•Patient Account Representative (PAR) inquires about missing Claim Payment

•Highlighted Benefits of the Step-Up/Step-Down Solution–Ability to Search and Filter across all incoming and outgoing transactions exchanged with

trading partners–Validation of 4010A1 and 5010 transactions and Lossless Translation between both

standards (Pre-Built Maps)–Batching and appropriate routing

•Steps for resolving the PAR’s problem–Check if we really did receive the claim–Review the entire path of the claim through various processing events i.e. through

validation, translation and routing to the right adjudication system–Find the payment generated by the adjudication system as a response to our claim–Provide details to the PAR so they can follow up with the clearinghouse

Use Case Scenario

Major Advantages: Speed, no “Rip and Replace” of existing systems and parallel testing of 4010A1 and 5010 transactions to assure proper billing and A/R

Architectural View of a Step-Up/Step-Down Implementation

Leverage our healthcare analytics knowledge to develop add-ons to the Edifecs5010™ Solution to provide assurance to for 4010A1 to 5010 Migration.

Key example: Edifecs Healthcare Transaction Repository (HTR) is a consolidated repository of 100% of the 4010A1 and 5010 transactions stored in a business-normalized schema.

• Perficient can develop analytical reports to compare the 4010A1 and 5010 transactions each day, week or month to assure the Chief Financial Officer that revenue and billing are under control

• Perficient can develop reports to analyze transactions by trading partner to balance transmissions inbound and outbound to the organization

• Perficient can develop reports to support the testing and quality assurance effort and re-use them for multiple clients

• Perficient can manage the performance testing of 5010 solutions

Added Value from the Perficient Approach

Pros• Rapid deployment for “late

starters”• Allows a phased approach to

remediation on your schedule• Defers total cost of 5010

remediation into more managed phases

• Edifecs has integration capabilities beyond 4010 to 5010 migration– HL7 Interoperability, XML

Cons• Still not an “easy” solution –

requires planning, implementation and testing

• Typically the solution requires EDI subject matter expertise

• Professional services may be needed to speed implementation to meet deadlines

• Small amount of “back end” systems remediation is needed

Solution Evaluation

• What are the biggest risks to your 5010 implementation right now?

• Were there any areas of the problem space or solution that the Edifecs solution does not address?

• When do you plan on starting with external testing?

Q&A

Next Steps

Daily unique content about content management, user experience, portals and other enterprise information technology solutions across a variety of industries.

Follow Perficient Online

Perficient.com/SocialMedia

Twitter.com/Perficient Facebook.com/Perficient

Thank You!