spending money and saving money: icd-10 and other hit...

Copyright 2014. Medical Group Management Association® (MGMA®). All rights reserved.

Spending Money and

Saving Money: ICD-10 and

Other HIT Initiatives

Richmond MGMA Mar. 13, 2014


Today’s Agenda

• Administrative Simplification

–Eligibility

–EFT/ERA

• ICD-10

• On the horizon

2


Patient Eligibility Verification

• Practices typically:

– Pick up the phone and attempt to verify

eligibility

– Log on a proprietary plan website

– Employ the “submit claim and cross fingers”

technique

– Play “chase the patient” for the outstanding

balances

3


Patient Eligibility Verification

Operating Rules • With new operating rules practices will receive:

– Health plan name and coverage dates

– Static financials (co-pay, co-insurance, base deductibles)

– Benefit-specific and base deductible for individual/family

– In/out of network variances

– Remaining deductible amounts

– All within 20 seconds

– Next morning if sent in batch mode

– Challenge: insurance exchange product 90-

day “grace period”

4


Electronic Funds Transfer /

Electronic Remittance Advice

5


EFT – Significant Potential for Efficiency

• Plan compliance, Jan. 1, 2014

• Estimates are that:

Providers could save ~ $3 per claim

• Opportunity to:

Manual handling of the mail, paper checks,

deposits

Reassociate payments with remittances

Get paid faster

• Watch out for “virtual credit card” payments


Operating Rules

• Automates the reassociation of EFTs and ERAs:

– Requires the health plan to release the EFT payment and ERA

within a reasonable timeframe (e.g. 3 days or less) if the

provider has enrolled for both transactions;

– Access to instructions from health plans on how to address late

or missing EFTs and ERAs;

– You receive the key data elements (“trace numbers”) in the two

transactions necessary for successful reassociation; and

– Requires health plans to utilize a uniform set of code

combinations for common business scenarios to convey details

of the claim denial or payment adjustment (Claim Adjustment

Reason Codes/Remittance Advice Remark Codes) to the

practice.

7


EFT Enrollment

–ACA standardizes enrollment data

and requires online enrollment

–CAQH now offer UPD EFT

enrollment module (caqh.org)

–Challenge: out of some 1200

health plans, currently only

participate (Aetna, Cigna,

Wellpoint, CareCentrix, Midwest) 8


MGMA EFT/ERA Guide

9


ICD-10

10


ICD-10

– Proving to be one of the biggest challenges

faced by industry

– Each link in the chain must be ready-with no

indication that ANY link is ready (incl govt)

– Implications of provider compliance: high cost,

decreased clinician/coder productivity

– Implications of non-compliance: disrupted $ flow,

potential of disrupted patient access to care

– MGMA most recent survey data, collected late

January:

11


CMS Administrator-Last Week

• “There are no more

delays and the

system will go live on

Oct. 1,”

• “Let's face it guys,

we've delayed this

several times and it's

time to move on.”

12


Implementation Steps

1.Organize Internally and conduct an Internal

Assessment

2.Evaluate Readiness

3.Engage and Train Clinical and Admin Staff

4.Clinical Documentation Improvement

5.Trading Partner Outreach

6.Recognize Costs and Developing Budgets

7.Perform Internal and External Testing

8. Identify Reimbursement Issues and Establish

Contingency Plans

13


1. Organize

ICD-10 Transition Team at The Core

● Leaders who represent impacted functions from coding

to technology; cover all areas identified; develop plan

● Working groups will be needed to ensure each area

gains momentum to execute according to the plan

– Detailed tasks linked to assessments

– Status updates to Transition Team

– Contribute to published updates to employees

● Develop ICD-10 overview presentation to explain the

importance and scope of this regulatory change

Action Steps: Establish transition teams and working groups, ensure they meet

regularly to maintain momentum (e.g. weekly), providing updates

Present ICD-10 overview presentation to employees Publish progress and alerts to employees from teams each month

ICD-10 Transition

Team

Physician Education

Coding

Technology

Finance

HIM

Others


2. Evaluate Readiness

Understand The Complete Picture

Define your process from the patient encounter to posting payment

(or update previous work), careful to recognize:

● Secondary processes such as denials processing and

reporting/BI (ad hoc and standard)

● Integration points with business associates/partners/payers

● Key roles in the process that influence coding

● Systems used to support the process, classifying each system

as having: Direct, Indirect, or no impact

Action Steps: Prepare simplified process document Review CMS resources made available on their website;

other industry resources are also very useful Evaluate and leverage the tools that fit your environment


Evaluate Readiness

Impact Assessments

Infrastructure and process changes will be essential to

succeeding in your transition to ICD-10. High level assessment

are important, but detailed assessments are key:

● High level assessment, addressing overall situation for

awareness, planning, and aligning teams/groups

● Productivity analysis, addressing increased complexity

● Financial analysis (837s), addressing impact of code maps

● Budget planning, managing the cost of the transition and the

ongoing cost increases to the organization

● Technology not ICD-10 ready, identifying dependencies

People

Process

Technology

Action Steps: Complete high level assessment document; use key elements to brief leaders

and physicians as needed Complete detailed analyses to drive necessary infrastructure, process, and

contract changes


3. Engage and Train Staff

Engaging Physicians

● Leverage results from detailed analysis of 837’s

– Overall impact of program to the practice

– Specialty-specific challenges identified

– Physician-specific statistics on mapping, if

available

● Target education materials

● Provide tools for monitoring and custom mapping

Action Steps: Present overview of program with detailed results Explain consequences of non-action, non-compliance Deliver targeted education program Solicit feedback; evaluate potential tools


• Patient encounter documentation

must be sufficient to support:

–Specificity (i.e., laterality)

–Granularity (i.e., diabetes)

–Medical necessity of the code

descriptor

4. CDI-Significant Challenge for Clinical Staff

18


Expected change in difficulty

What is the expected change in difficulty to accomplish the following

practice activities under ICD-10?

Answer Options

% of respondents that indicated

“Somewhat or much more difficult”

June 2013 Jan. 2014

Ability to document the patient encounter 89.1% 89.8%

Ability of clinician to select appropriate

diagnosis code 95.8% 97.6%

Ability of coding staff to select appropriate

diagnosis code 92.3% 93.1%

Ability to compare new diagnosis data in

ICD-10 with previously collected diagnosis

data using ICD-9

91.7% 87.8%

19


• Take a broad selection of previously and

successfully adjudicated claims (most

frequently billed codes) and: – Recode for ICD-10 (was the documentation

sufficient?)

• Dual code claims being developed

• Teaching opportunity

• Utilize peer-to-peer dialogue

• Explain ramifications

Working with your Clinicians: Documentation

Assessments

20


Assigning Codes

• Clinicians have several options:

– Book

– Superbill (1 page turns into 10)

– Computer program

– Mobile device

21


ICD-10 in iTunes

22


5. Trading Partner Outreach

23


Trading Partner Outreach-Software Vendors

– Ascertain what systems need to be upgraded or replaced. Then ask vendors:

• Upgrade or replacement?

• Which version(s) will be upgraded?

• Costs covered under maintenance agreement?

• Timeline for installation / testing

• Hardware upgrades required?

• Utilize 4010 or 5010?

• Will software permit both ICD-9/10 codes?

• Are they offering any training? 24


Trading Partner Outreach-Clearinghouses

–Questions to ask:

• What ICD-10 services will you provide?

• What if we are on 4010 (workarounds)?

• What will be the cost of your services?

• When can you accept test claims?

• Will you publish a listing of payer

readiness and payer testing

schedules?

25


6. Recognizing Costs and

Budgeting

26


• Primary expenses to budget for:

– Impact assessment

– Software/hardware

– Workflow redesign

– Staff training

– Superbill redesign

– Reduced clinician productivity

Recognizing Costs

27


New Cost Estimates

Typical Small Practice (3 FTEs)

Typical Medium Practice (10 FTEs)

Typical Large Practice (100 FTEs)

2008 Estimated Costs

$83,290 $285,195 $2,728,780

2014 Estimated Costs

$56,639 - $226,105 $213,364-$824,735 $2,017,151-$8,018,364

28


7. Internal and External

Testing

29


Testing-Internal

30

● Complete internal testing to ensure all systems and work

processes can function properly with ICD-10 codes

– Can you create administrative transactions, claim, eligibility

requests, prior authorizations, etc.?

– Can you generate other reports – quality, public health, etc.?

– Is your PMS – EHR interface working?

– What about other practice software that utilize ICD codes (i.e.,

case management, clinical trials)?

● Include testing manual processes to see how they will

flow with system changes

● Give yourself sufficient time to fix problems


Working with Your CH

• Majority of claims routed through

clearinghouses

• CHs are reporting up to 20% of practices

still on 4010

• They can help…but not solve your ICD-10

issues

• Without the clinical documentation, the CH

cannot assign or cross-walk codes

31


Ask Your CH for the Following Reports:

• List of your top claims:

– Paid (volume, amount)

– Rejected (payment policy/documentation)

– Pended (payment policy/documentation)

– Where unspecified codes were used

• Leverage these reports during your CDI

exercises

32


Testing-External

33

● Testing should involve all of the steps a claim

goes through for processing

● Identify who to test with and when they will test

● If end-to-end testing is done, review the 835

closely to see how the claim processed

– Did the claim reject or pend?

– Is the reimbursement what you would have received

under ICD-9?

– Were there any adjustments in the payment?

● Allow time to fix any issues identified during

testing


Anthem-Testing

• We are conducting File Validation Testing for providers who are

EDI direct submitters. We have chosen TIBCO Validator® as our

primary testing tool that offers unlimited testing of your EDI HIPAA

transactions. This self-guided, web-based processing application is

equipped to test file formats and edits as they pertain to ICD-10.

• To get started, visit our Anthem EDI webpage where you will find

the “Free On-Line HIPAA Validation Testing” link to register for

Validator® and more information and the guidelines for using the

tool.

• If you are not an EDI direct submitter, you will need to partner with

your claims submission vendor (clearinghouse, billing company,

etc.) to test with us.

34

http://www.anthem.com/edi/


Anthem Testing

• End-to-End Test

• An End-to-End test of our systems and business

functions which demonstrates ICD-10 readiness

levels both internally and externally launches in

1st quarter 2014. The End-to-End test will

engage selected providers, hospitals, clinical

EMR providers, vendors, data trading partners

and others to help ensure we are ready for ICD-

10 across the industry. We will share guidance

and learning gained from these tests with you as

we prepare for ICD-10.

35


Critical Issues

• Little industry testing taking place

–Many software vendors not ready

–Workers comp remains on ICD-9

–Are plans ready? (Edits not getting

to clearinghouses.)

–If no testing, the go live date

becomes the “testing” (a la

healthcare.gov) 36


Medicare Testing

• Medicare/Medicaid readiness level

unknown

– First said no testing (MGMA letter)

– November 2013 announced “front-end”

testing in March (MGMA letter)

– Just announced “end-to-end” testing, but…

• Only limited to 500 providers (all types)

• Won’t start until July

• When will results be published? 37


8. Identify Reimbursement Issues and Establish

Contingency Plans

38


ICD-10 Reimbursement Issues

39

Changes to payers policies Will payers restructure fee schedules

based on diagnoses?

Will payers change any requirements for reimbursement?

Will payers require more attachments /documentation reviews?

Release of payer edits to CHs Will they be done in time to test?


– Will unspecified be covered?

– What if payers adopt different policies?

– Does not guarantee payment?

– Will they decrease payment?

– Paid initially then rejected?

– How can a practice prepare?

• Ascertain payer policies asap and train admin

and clinical staff

• Limit use

How will Payers Handle “Unspecified”?

40


Contingency Planning

41


Overall Readiness Level

Please rate your practice’s current overall readiness level for ICD-

10 implementation:

Answer Options June 2013 Jan. 2014

Not yet started our implementation 55.4% 38.4%

Somewhat ready 33.6% 40.9%

Approximately half completed 6.2% 11.3%

Made significant progress 4.7% 9.4%

Completely finished with our implementation 0.1% 0%

42


Contingency Planning-The “What Ifs” I

43

● What if PM is not upgraded?

– Look at your options for claims submissions-these could include online portals, dropping to paper, working with a billing service

– Each will decrease productivity and cash flow and cost you money

– Look at alternative software

● What if your RCM team is not ready?

– Test staff capabilities

– Limit vacation time around Oct. 1

– Look at bringing in extra staff short term


Contingency Planning-The “What Ifs” I

44

● What if you experience cash flow disruption?

– Limit spending leading up to compliance date

– Set aside cash reserves

– Establish a line of credit (can be problematic)

– File (ICD-9) claims on time/follow up on

pended/rejected claims prior to Oct. 1

– Talk to your payers about any “safety net”

actions they will take to pay claims


What are the Government’s Options?

1. Do nothing

• What are the ramifications?

2. Extend the compliance date

• Who is opposed?

3. Allow dual use of both ICD-9 and ICD-10

• Who claims this can’t be done?

4. Relaxed edits

• Would this apply ONLY to Medicare/Medicaid?

5. Enforcement delay

• How would this help?

45


Critical Take-Aways

46

● Be as prepared as possible for ICD-10

● Staff buy-in/training is critical

● Be aggressive with your trading partners

● Monitor your claims processing and reimbursement closely

● Focus on codes and payers that make up high volume/high

dollar reimbursement

● Ideal testing will test the entire flow of a claim to the payer

and back with a remittance advice

● Any testing is better than no testing

● Avoid testing “in production” after Oct. 1

● Expect cash flow interruptions

● Prepare for the “what ifs”


The Near Future for Practices

47


Smart Cards and Admin Simp

• Problems associated with patient matching/patient ID cards

• Machine readable patient ID cards can improve practice operational efficiency by:

– Effectively identifying the patient

– Permitting card-PM system interface thus eliminating rekeying errors leading to claim issues

• Reduces resubmission and re-adjudication costs for both provider and payer

– Permitting initiation of real-time insurance eligibility verification and allowing practices to utilize the new 270/271 operating rules

– Permitting initiation of real-time claim “adjudication”

48


“Smart” Cards

49


Practice Management System

Software

• Problems:

– Doesn’t always allow practice to take

advantage of the new standards

– Brochures and salesmen

– Identity theft

– Patient ID cards that lack all utility

50


PM Issues

• AMA-MGMA PMSS Directory

• We would like a more formal certification

process in place

• ACA plan requirement, ATCB MU process

• Increased assurance that we can not only

meet federal mandates, but truly take

advantage of the ACA admin simp

opportunities


PM Accreditation

52


In Summary

• Significant opportunities to automate your practice

• Focus on eligibility and EFT as “low-hanging fruit”

• Talk to your vendors and CHs about opportunities,

plans about compliance

• Get started on ICD-10…it may be here to stay

• MU Stage 2 will be tricky-talk to your

colleagues/vendors

• Keep one eye on tomorrow’s opportunities

• Look to MGMA as your trusted partner!

53


Questions? Thank You!

Robert M. Tennant

[email protected]

202.293.3450

54

mailto:[email protected]


Resources mgma.org/ICD10

55


CMS (NGS): http://www.cms.gov/Regulations-and-Guidance/HIPAA-

Administrative-Simplification/Affordable-Care-Act/End-to-End-Testing.html

56


New CMS Resource: www.roadto10.org

57


Recent MGMA Member-Benefit Resources December 2013 – February 2014

• MGMA/AMA 2014 ACA Exchange Checklist

• EFT and ERA Guide

• Requesting payment via EFT sample letter

• Final 2014 Medicare Physician Fee Schedule Analysis

• General Medicare Update for 2014 webinar on-demand

• Updated MGMA/AMA Ordering/Referring Fact Sheet

• Meaningful Use: Top Member Questions

Get the latest in regulatory and legislative news straight from the nation’s capital through the Washington Connection, published weekly

by our Government Affairs team.

58

http://www.mgma.com/government-affairs/issues-overview/aca/mgma-ama-medical-practice-checklist-for-2014-aca-exchange-implementation

http://www.mgma.com/government-affairs/issues-overview/health-information-technology/administrative-simplification/mgma-eft-and-era-guide

http://www.mgma.com/government-affairs/issues-overview/health-information-technology/administrative-simplification/sample-letter-to-request-payment-via-eft

http://www.mgma.com/government-affairs/issues-overview/medicare-payment-policies/medicare-physician-reimbursement/final-2014-medicare-physician-fee-schedule-analysis

http://www.mgma.com/store/education/online/webinars-on-demand/general-medicare-update-for-2014-on-demand

http://www.mgma.com/government-affairs/issues-overview/medicare-payment-policies/medicare-provider-enrollment/mgma-ama-ordering-referring-fact-sheet-updated

http://www.mgma.com/government-affairs/issues-overview/federal-quality-reporting-programs/what-mgma-members-are-asking-about-meaningful-use

http://www.mgma.com/Washington


Visit our website for full pricing information

and to explore all of our membership options,

including special rates for group memberships.

Use the code “GAMEM” to wave the application fee

when you sign up for an annual membership today!

59

http://www.mgma.com/membership/not-a-member/become-a-member-of-mgma-today

http://www.mgma.com/membership/not-a-member/mgma-group-membership


Thank you!

Robert Tennant

[email protected]

202.293.3450

mailto:[email protected]


New Approach to MU Penalties

• After several MGMA letters…

• CMS announced exemption for the following:

– 2014 EHR Vendor Issues:

• The eligible professional’s EHR vendor was unable to

obtain 2014 certification or

• The eligible professional was unable to implement

meaningful use due to 2014 EHR certification delays.

• CMS Tipsheet: http://www.cms.gov/Regulations-and-

Guidance/Legislation/EHRIncentivePrograms/Downloads/PaymentAdj_

HardshipExcepTipSheetforEP.pdf

61


MU Tips

• Review closely your current or potential vendor

contract for upgrade schedule

• Carefully review ROI (cost/penalties vs

incentives)

• Pick the right software for your practice, not

necessarily the cheapest, or even one that

meets MU

• Be mindful of HIPAA security assessment—

leading cause of failed MU audits

• www.mgma.org/meaningfuluse

62


Resources

MGMA ICD-10 Resources

• http://www.mgma.org/icd10

CMS ICD-10 Web Resources

• http://www.cms.gov/ICD10/

• http://www.roadto10.org

http://www.mgma.com/icd10

http://www.cms.gov/ICD10/

http://www.roadto10.org/


Resources

CDC Web Page (General ICD-10 information)

– http://www.cdc.gov/nchs/about/major/dvs/icd10des.htm

ICD-10-CM files, information and GEMs between ICD-10-CM and ICD-9-

CM

– http://www.cdc.gov/nchs/about/otheract/icd9/icd10cm.htm

ICD-10 home page (WHO)

– http://www.who.int/whosis/icd10/index.html

NCHS – Basic ICD-10-CM information

– http://www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm

CMS – ICD-10-PCS information

– http://www.cms.hhs.gov/ICD10/02_ICD-10-PCS.asp

WEDI – ICD-10 Implementation

– www.wedi.org

64

http://www.cdc.gov/nchs/about/major/dvs/icd10des.htm

http://www.cdc.gov/nchs/about/otheract/icd9/icd10cm.htm

http://www.who.int/whosis/icd10/index.html

http://www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm

http://www.cms.hhs.gov/ICD10/02_ICD-10-PCS.asp





http://www.wedi.org/

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