Get the most out of care management

WHEN EXECUTED PROPERLY, from start to finish, the benefits of ICD-10 migrations for healthcare payer organizations can be significant. With a revised deadline of Oct. 1, 2014, time allows for more than mere compliance. Plans can achieve enterprisewide transformation and improvement across core administration, care management and constituent engagement. 

• Successful ICD-10 transitions can drive improved core administration efficiencies that:

• Provide opportunities to increase Medicare and Medicaid reimbursement;

• Refine payment policies for groupers (DRGs, APGs, etc.);

• Increase the amount of data to help manage underwriting risk;

• Support value-based benefit and value-based reimbursement programs; and

• Drive better claims subrogation.

Payers that leverage ICD-10 to help improve core administration will be able to identify and resolve issues faster and support more accurate trend, cost and reimbursement analysis-all potentially leading to lower costs, better decision making and a competitive advantage.

Health plans that take advantage of ICD-10’s detailed coding information will be able to refine and drive more robust care management programs. The expanded codes: 

• Allow for more detailed stratification; 

• Help identify disease states earlier; and 

• Include indicators for underdosing (intentional vs. unintentional), severity, lifestyle and other factors that support better outcomes and reduced costs. 

ICD-10 presents payers with an opportunity to deliver more profitable and innovative care 

management programs, including value-based benefit and reimbursement designs that encourage effective care, discourage use of inappropriate care and actively engage constituents in a culture of health. Payers that leverage ICD-10 can differentiate themselves by allocating resources more efficiently, ensuring the highest return on their care management investment. 

ICD-10 also helps health plans in other ways, such as refining contract strategies for more accurate and efficient payments. Many payers are negotiating contracts that extend well beyond 2014. By including provisions for ICD-10 codes today, health plans may save money and a lot of headaches tomorrow. 

The update also provides greater transparency for members, providers and payers. Expanded codes enable providers to make better diagnosis and care decisions based on more in-depth patient history, which enables members to make better health decisions. With detailed data, payers can design innovative benefit programs that promote wellness and encourage engagement.

What steps should a healthcare payer organization take to deliver on the promise to help ensure a successful, systematic and truly impactful transformation? The recommended steps fall into three categories: people, process and technology.

PEOPLE

A health plan might obtain the help of an experienced consultant. This advisor should have dozens of HIPAA 5010 and ICD-10 projects under its belt. It also should bring road-tested experience in the health-plan space, serving hundreds of payers touching millions of lives.

Look for a dedicated ICD-10 consulting team ready to help the payer understand the challenge and develop and execute a comprehensive plan on time, on strategy and on budget. The advisory team should execute against the plan-everything from strategic alignment, detailed gap analysis and impact assessment to testing, implementation and post-implementation support. The team should employ reliable methodologies, best-practice approaches and advanced technologies, all delivered by seasoned, certified consultants who can ably support the broad range of business, IT, clinical and financial aspects of an ICD-10 transition. 

Even the very best advisory team will be one that recognizes the limits of its knowledge and seeks to learn from and continuously improve upon the experience of others. The team will systematically incorporate client input on an ongoing basis, through a standing committee or work group comprised of dozens of actively participating payer organizations.

PROCESS

ICD-10 requires a systematic approach. One such approach that helps ensure a smooth, enterprisewide transformation employs three steps: assess, remediate and test.

During the assessment, the health plan’s business, technical and migration needs should be analyzed. Analysis identifies the order of magnitude that will be required to address ICD-10 compliance.

In remediation, the payer’s ICD-10 goals should be translated into an actionable project plan including validation of the business requirements, re-configuration needs, code mapping, environment planning, IT approach, training and communications planning. The health plan’s trading partner activity must be coordinated, as well, throughout the migration.

During testing, the consulting team should focus on developing and executing the ICD-10 testing strategy. It should also implement testing plans and comprehensively execute the go-live plan to its logical conclusion, through post-implementation support.

TECHNOLOGY

The best ICD-10 advisors will employ the best technology. For example, one such technology is a mapping tool that automates much of the mapping and translation that must be done, thereby reducing the cost and time of the migration project.

Another technology solution identifies the ICD-9 codes most used, analyzes how much the payer pays against each, and models ICD-10 mapping to maintain financial neutrality. This solution supports the most informed contract negotiations with provider organizations.

Another tool might ease and accelerate configuration during migration, as well as the rework required if the payer decides to change ICD-10 mappings after testing is conducted. This technology should automate the process of loading ICD-10 codes for corresponding ICD-9 codes while updating related configurations. Saving on work hours, the configuration toolkit allows the project team to renovate in multiple test environments.

The Hawaii Medical Service Assn. (HMSA), an independent licensee of the Blue Cross and Blue Shield Assn. that covers half the state's population, is making the transition. 

In view of project challenges and the need for a smooth transition to ICD-10, HMSA partnered with its advisor to develop a configuration toolkit that would automate and accelerate the data-migration process, thus reducing the amount of time required to update ICD-9 code configurations to ICD-10 and enabling the correct coding and adjudication of claims after migration. Such automation could save up to $1 million or more. 

If done manually, the ICD-10 renovation would have required approximately 46,000 staff hours of work. As the migration progresses, HMSA will provide comprehensive training for employees and network providers.  MHE