ICD-10 END-TO-END TESTING

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ICD-10 END-TO-END

TESTING

Mark Lott

Abstract

Delivering a social based cloud testing platform that utilizes business testing processes to walk claims through an end-to-end testing process to prove both coding and reimbursement policies for ICD-10 are successful in their implementation across the healthcare industry

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Executive Summary

We greatly value this opportunity to demonstrate the cost effectiveness and collaborative nature of using the National Testing Program for end-to-end testing and become one of your strategic service partners.

The ICD-10 National Testing Program (NTP) is a cloud based highly collaborative and social testing platform that delivers a vital testing platform, processes and end-to-end connectivity. This work-social testing environment offering substantial operational cost savings, builds on long term ROI through reusable environment and test data and greatly reduces the burdens of external testing for ICD-10 testing and future healthcare implementations.

The demands and requirements for end-to-end testing will increase a hundred fold over the coming years and is needed to increase the quality and efficiency of testing. The current testing frameworks used for 4010, NPI and 5010 have outlived their usefulness because wider industry collaboration is now the driving force behind better, more informed testing and long term ROI.

The National Testing Program delivers strategic long term cost savings through a social testing framework that fosters collaboration on a grand scale. This new type of testing platform is crucial in a movement of healthcare towards increasing the collaboration and capabilities for testing transactional lifecycles.

ICD-10 End-to-End Testing Problem

With the advent of ICD-10, healthcare requires a more advanced, more thorough method for testing with their trading partners. Testing and test data are not silo local events, they are highly interconnected national events. The industry wastes millions of dollars every year by every healthcare organization trying to recreate test data in a silo when the majority of transactions required for testing are very similar across the entire industry. It is a significant investment that deprives strategic initiatives of needed funding and focus. Covered entities cannot afford to continue to incurring expense, time consuming test costs when there are no promises of common testing or cost savings from tools and no guarantee of interoperability. The NTP was developed as a collaborative solution providing the best of both worlds – commonly used industry-wide test data blended with a mix of participant’s internal data for maximized coverage with the highest value test datasets. The NTP is needed because as an industry we do not collaborate enough to accomplish the level of testing currently required because of disconnected process and a lack of national testing coordination to a level a depth and breadth truly required for substantial testing initiatives.

Realistic end-to-end testing requires clinically accurate test data to more closely mirror production and provide a common testing standard from which all entities can measure their

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implementation success. The NTP delivers a testing framework that can be made available to every organization and one that greatly reduces the cost of ICD-10 testing.

Testing with the ICD-10 National Testing Program will:

 Enable providers to determine if additional assistance of training will be necessary  Save time, effort and money by providing standard test data as opposed to having to

each entity create all of their own base sets.

 Allow providers to be given the results of processed claims to advise the outcome of payments (or denials).

 Demonstrate how collaborative end-to-end testing works and how it can help your organization through ICD-10 implementation.

Concept of Asynchronous Testing and Proxy Testing

The ICD-10 National Testing Program is a full scale collaborative testing platform for healthcare. It provides an open and transparent process for healthcare organizations of all types and sizes to test with their trading partners for ICD-10 coding, compliance and reimbursement testing.

For providers, healthcare providers, plans, and their business partners to be ready for ICD-10, a collaborative testing environment is paramount to success. Our multi-stakeholder platform represents the largest testing community of its kind by including every entity type within the healthcare lifecycle.

The testing platform is designed to provide the following benefits:

 Sandbox for uncovering as many issues as possible collaboratively  Early coding inaccuracies

 Clinical documentation issues  Vendor upgrade issues

 Clearinghouse issues  Healthplan issues  Rev Cycle issues

 Operational issues on cutover  Compliance issues

 Code sets  EDI Validation

 Extremely affordable for all participants

 Delivers long term ROI by dramatically reducing coordination tasks and test case traceability

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NTP Testing Benefits

Immediate NTP Testing Benefits:

 Dual-Coded Medical Records and Claims  Common Repository of Payer Edits  ICD-10 Cutover Operational Guidelines

 Vendor Testing Success Indicators and Certification  Clearinghouse Testing Success Indicators

 Healthplan Testing Success Indicators and Certification

 Proxy Testing for Vendor, Clearinghouse, Healthplan and Rev Cycle

 Local and National Coding Accuracy Statistics by Med Specialty/DRG/Case Mix  Local and National Coding Proficiency

 Local and National Quality Measures

 EDI Compliance Differences and Alignment

 FAQ Library Across All ICD-10 Testing Requirements  Provider Outreach and Education

 Clinical Documentation Improvement

 ICD-10 Testing Best Practices and Lessons Learned  ICD-10 Help Desk

Long Term NTP Testing Benefits:

 Plug and Play Framework for all Future Testing Needs  High volume reusable test data with expected results  Continual ICD-10 Coding Accuracy Analysis

 Continual Trading Partner Testing

 Continual End-to-End Testing and Certification  Continuous Provider Outreach and Education  Testing Best Practices and Lessons Learned  Permanent Testing Help Desk

 Common Repository of Payer Edits

 Vendor Testing Success Indicators and Certification  Clearinghouse Testing Success Indicators

 Healthplan Testing Success Indicators and Certification

 Proxy Testing for Vendor, Clearinghouse, Healthplan and Rev Cycle

 Local and National Coding Accuracy Statistics by Med Specialty/DRG/Case Mix  Local and National Coding Proficiency

 Local and National Quality Measures

 EDI Compliance Differences and Alignment

 FAQ Library Across All ICD-10 Testing Requirements  Permanent Provider Outreach and Education for Testing

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Technology Platform Features

The National Testing Program is built upon a highly scalable cloud-based platform residing in the Amazon EC2 cluster. It is a social Business Process Management System that has 10 key core components:

 A process orchestration engine to drive the progression of coding and testing work in structured and unstructured processes or cases

 A model-driven composition environment for designing testing processes and their supporting activities and process artifacts

 Content interaction management to support the progression of work, especially test cases, based on changes in the content itself (such as diagnosis, policies, contracts)  Human interaction management to enable people and organizations to naturally

interact with the processes and fellow community members they are involved in

 Connectivity to link processes to the resources they control, such as people, systems, data, event streams, goals and key performance indicators (KPIs)

 Active analytics (sometimes called continuous intelligence) for monitoring activity progress, and analyzing activities and changes in and around processes

 On-demand analytics to provide decision support or decision automation using predictive analytics or optimization technology

 Business rule management to guide and implement testing process agility and ensure compliance is met throughout the testing process

 Management and administration to monitor and adjust the technical aspects of the BPMS

Work / Social Testing for Healthcare

The National Testing Program is a Business Process Modeling Suite which seamlessly integrates work automation with mobile and social capabilities with all the data, processes, documents, and collaborations in one environment on any device through a simple social interface.

End-to-End testing and coordination involves many virtual teams working together on projects and decision making. This requires the use of technology that enables activity streams, blogs, communities, discussion forums, participant profiles, content driven decision engines and wikis.

The result is unique capabilities of:

 Visibility across all test cases and trading partners

 Empower business users with the ability to work anywhere and collaborate anytime

 Integrated testing processes and enterprise data to drive better, faster more accurate testing results

 End-to-End testing and certification

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 Mobile Access

 News and Alerts

 Work Tasks

 Testing Artifacts

 Reports and Analytics

 Social Collaboration

 Case Management

Figure 1 - National Testing Program Architecture

The National Testing Program Beyond ICD-10

The NTP is a cloud based plug-n-play testing methodology and platform that establishes a long term, highly reusable environment and process for all future testing events. This includes HIPAA EDI, ICD-10, ACO, HIE, Vendors, Coding, Policies, Benefits, ASO, Reimbursements, Repricing, Compliance testing, etc.

Collaborative Based Proxy Testing

ICD-10 National Testing Program provides an open and transparent process for healthcare organizations of all types and sizes to test with their trading partners through a proxy based testing process. Selected critical trading partners will be tested end-to-end and act as the proxy for the majority of participants that will not be completely tested. These entities will be grouped across common diagnosis codes, DRG’s, vendor and clearinghouse profiles. These healthcare supply chain demographics are used to uncover all the similarities of trading partners and leverage it to describe testing success indicators by the few for the many. This allows groups of trading partners to be tested in an asynchronous process using the

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end-to-end testing partners selected as the proxy to demonstrate successful testing to the whole community.

Figure 2 - Proxy Based Testing Process

Run Claim Analytics Determine Dx, DRG, CMI Determine Submitters Group By Proxy Submitters Submitters Paid by DRG Submitters Paid by CMI Submitters Paid by % Pull ICD-9 Claims for Submitters Pull Submitter Charts Dual Coding of Medical Records Resubmission of ICD-10 Claims Adjudication Payments Compared to ICD-9 Obtain Signoff from Payer and

Submitter Initiate Encounter at Submitter Validate Coding Validate Claim Clearinghouse Conversion Inform Other Submitters Share Medical Records Share Payments Data Submitters Not Tested Given Success Metrics

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Components of the National Testing Program

The functionality derived from the NTP work social platform provides for functional and

operational testing delivered on dual tracks. Two main testing programs comprise the NTP, the first tests the trading partner flow from the encounter process through to the healthplan EDI gateway and the second tests selected trading partners and transactions designed for end-to-end testing.

NTP - Testing Track 1: Coding Accuracy and Partial Onboarding

 Dual Coded Records Uploaded and Shared Across the Community  Records represent the most needed and frequent encounters  Measures Coding Accuracy

 Measures Coding Proficiency

 Shows the Coding Deviations for “Reality Testing”

 Medical record testing artifacts stay constant through regulatory change  Highly reusable test bed for all future testing requirements

NTP - Testing Track 2: Full Scale End-to-End Testing for Selected Participants

 End-to-End Testing

 Selected submitters, clearinghouses and payers participate  Medical specialty coverage

 High volume coverage  ICD-9 to ICD-10 compare

 Exact member demographics for matching  Adjudication rates

 Claim accuracy rates

 Common reimbursement proxy testing

NTP Reality Based Testing Approach

It is not nearly enough to only test the correct ICD-10 coding answers. The testing must reflect the reality of ICD-10 and that is that it is new and will take time to learn and apply the coding guidelines correctly. This raises the immediate need to also test the wrong answers and near misses uncovered during the coding accuracy testing process. The NTP captures these coding deviations and creates additional claims for the healthplans to determine the levels at which coding errors affect reimbursements. This data will be used to educate the participants in which errors will cause rejections and which ones are superficial.

The coding accuracy testing also identifies which areas of ICD-10 terminology that the coders may need additional refreshers on. This is important because the transactions being testing the NTP are the most common across the production landscape and we as an industry need to ensure the most common claims result in successful reimbursements.

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In summary, the testing effort must include testing the correct coding representations in ICD-10 but also the coding errors. Performing these tests in a collaborative methodology shares these lessons learned across a large cross section of the industry which only improve the quality of the ICD-10 implementation.

Selection of Testing Partners and Test Data Criteria

 Clearinghouse claim analytics by submitter

o Top 10 ICD-9 codes by  Physicians

 Physician Groups  Rural Hospitals  Skilled Nursing

 Small, Medium and Large Institutions

 Plus Additional Places of Service and Bill Types as Required

 Healthplan claim analytics by submitter o Top 10 ICD-9 codes by

 Physicians

 Physician Groups  Rural Hospitals  Skilled Nursing

 Small, Medium and Large Institutions

 Plus Additional Places of Service and Bill Types as Required

 Alignment of Analytics to Identify Most Common Transaction Threads by o Med Specialty

o DRG

o Case Mix Index

 Alignment of Surveys to Identify Most Test Worthy Candidates o Vendor Upgrades complete

o Pre-Testing Readiness Complete o Clearinghouse Readiness

o Healthplan Readiness

 Setup of Proxy Testing Standards

o Identification of Confirmed Participants  Hospitals

 Physicians  Clearinghouses  Healthplans

o Identification of Available Testing Slots  By Healthplan

 By Physician or Hospital Type o Identification of Test Cases

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 Ensure Test Case Mix Spread Across All Submitter Types o Healthplan Proxy

 Group Submitters by Common Reimbursement Process

 DRG

 Case Mix

 Percentage Over

 Identify End-to-End Participants for Proxy Testing

 Ensure Broad mix of Vendor/Clearinghouse/Submitter Type Testing o Identify Claims for End-to-End Testing

 Pull claims by Confirmed Participants

 Identify Medical Record and Pull Charts from Submitters  Crowdsource ICD-10 Coding

 Initiate Transaction Testing Process

Testing Process

o Encounter entered through standard submitter workflow via upgraded software o Clearinghouse processes file and sends to healthplan

o Healthplan adjudicates claim and verifies reimbursement accuracy o Remittance sent to Rev Cycle for agreement and signoff

o All submitters benefiting by claim testing success notified o Metrics captured for

 Vendors  Coders  Billing

 Clearinghouse  Healthplan

o Show testing success matrix demonstrating wide variety of testing across the majority or all of the medical specialties and institution types

o Established a reusable testbed of dual coded records, claims, remittances of all of the most important transactions across the entire healthcare spectrum

o Continue to build upon the testbed for greater depth and breadth over time o Utilized for all HIPAA transaction testing

Scope of Work

Lott QA Group will work with plans to coordinate and identify the selected trading partners based on key demographics of claims and submitter profiles along with the required ICD-10 readiness levels for full scale testing requirements. The submitters will be enrolled into the NTP and will be managed throughout the testing process ensuring timely and accurate testing deliverables are accomplished in accordance with the plans acceptance criteria.

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ICD-10 Dual Coding Analysis

The Lott QA teams will extract and review institutional and professional claims across the selected trading partners identified for end-to-end testing. These claims and medical records should encompass the following KPI’s:

1. The top 20 DRG’s for Commercial 2. The top 20 DRG’s for Medicare 3. The top 20 DRG’s for Medicaid

4. The top 250 ICD-9 Diagnosis codes for Commercial 5. The top 250 ICD-9 Diagnosis codes for Medicare 6. The top 250 ICD-9 Diagnosis codes for Medicaid 7. The top 100 CPT codes for Professional

Upon review and analysis of the claims and the submitter’s medical records our coding teams will produce the following deliverables:

 Individual chart review worksheets with ICD-9 validation and ICD-10 code assignment  Line-item comments, findings and recommendations at the code level for each discharge

or encounter reviewed related to clinical documentation and code assignment

 Re-grouping of MS-DRG for inpatient claims post-ICD-10 code assignment to develop DRG shift and potential financial impact by claim

 Provide the dual coded medical records to Plan for coding review prior to submission as ICD-10 claims under test

 Manage the complete processing of the end-to-end claims required for testing from the encounter through the vendor software, clearinghouse(s) and delivery to the Plan EDI gateway

 Manage the return and signoff of the ICD-10 remittance to submitters demonstrating accurate payments

 Certify ICD-10 compliance through the traceability of the testing artifacts from end-to-end  Use the successful end-to-end tests as a proxy for all other Plan submitters under the same

reimbursement methodologies to show a much greater audience that their organizations will be processed successfully post ICD-10 go-live.

ICD-10 Testing Deliverables

Testing Deliverables:

 Full Scale Enterprise Testing Platform  Master Test Plan and Master Project Plan  Peer Reviewed Medical Records

 Dual Coding Worksheets

 ICD-10 Coding Readiness for Selected Plan Submitters  Test Case Descriptions

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 Weekly Reports and Milestone Based Reports  Testing Process Flows

 Test Execution Process  End-to-End Testing Process  ICD-10 Certification

Pricing

Pricing contains the work effort described in the previous sections including but not limited too;  Enrollment of Submitters into the NTP

 Cloud Based Testing Platform for Plan and its Submitters

 Weekly Webinars and Orientations for Submitters on Testing Procedures  Coordination and Management of Submitter Readiness

 Grouping of Proxy Based Submitter Testing Groups

 Complete Onboarding of Selected ICD-10 End-to-End Submitters

 Dual Coding of Submitter Medical Records Tied to the Production Claims Under Test  Alteration of Existing Production Claim to Reflect the ICD-10 Coding

 Member Alignment Across Claims  End-to-End Testing Management

 Proxy Testing and Communication to Plan Submitters  Project Management

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Participation Costs for the ICD-10 National Testing Program

Organization Size Pricing*

Institutional Providers < 25 Beds $1,000

26 - 50 Beds $2,000 51 - 100 Beds $3,500 101 - 200 Beds $5,000 201 - 299 Beds $6,000 300 - 399 Beds $7,000 400 - 499 Beds $8,000 > 500 Beds $10,000

Group Physican Practice 1 - 5 Physicians $1,000

6 - 10 Physicians $2,000 11- 24 Physicians $3,500 25 - 50 Physicians $5,000 51 - 100 Physicians $7,000 101 - 200 Physicians $8,000 > 200 Physicians $10,000 Healthplans** < 250,000 Members $2,500 250,000 - 500,000 Members $3,750 500,001 - 750,000 Members $5,000 750,001 - 1,000,000 Members $6,500 1,000,001 - 2,000,000 Members $8,000 2,000,001 - 3,000,000 Members $10,000 3,000,001 - 4,000,000 Members $15,000 4,000,001 - 5,000,000 Members $20,000 > 5,000,000 Members $25,000 Clearinghouses*** < 1,000 Submitters $2,500 1,001 - 2,500 Submitters $3,750 2,501 - 5,000 Submitters $5,000

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5,000 - 10,000 Submitters $6,250

10,001 - 25,000 Submitters $7,500

25,001 - 50,000 Submitters $10,000

> 50,000 Submitters $15,000

Software Vendors**** < 50 Client Install Base $2,500

51 - 100 Client Install Base $3,750

> 1000 Client Install Base $10,000

** End-to-End certification is included for participants that complete the necessary requirements

*** Clearinghouse ICD-10 Readiness Certification is included for participants that complete the necessary requirements

**** Vendor ICD-10 Readiness Certification is included for participants that complete the necessary requirements

Organizations that sponsor their submitter participation fees through direct purchase or through our corporate sponsorship program will receive 10% discount across all their entity types

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Assumptions

The following assumptions inform the engagement team’s scope, approach, and budget. Notwithstanding anything to the contrary below, client’s obligations shall be limited to providing what client considers to be reasonable cooperation and access to certain materials and information described below. It shall be the Vendor’s sole responsibility to provide Plan with notice under the Master Agreement to the extent that such reasonable cooperation and access are not provided and Plan shall use commercially reasonable efforts to correct any such access problems.

1. Client and the engagement team will work collaboratively to facilitate the success of the project in the proposed timeframe.

2. Client will commit team members to this project and make available representatives for interview within reasonable time periods to complete the project. In addition, other subject matter specialists will be provided from client on an as needed basis.

3. Adequate workspace and accommodations will be provided at field sites and the corporate facilities for the engagement team including access to phones, internet, printers, copying and other business support services.

4. Client is responsible for providing requested information to facilitate the project, including charge rates for documented facility services, coordinating planning sessions, and scheduling interviews with key Client participants, in accordance with agreed dates. 5. Client will provide administrative support to schedule interviews, workshops, and Plan

Committees as needed.

6. The engagement team will have full access to key process stakeholders and relevant Client personnel and will receive timely responses to inquiries and requests.

7. Client n will communicate the intent of the project to appropriate personnel to facilitate the progress of the project as part of the initial awareness campaign.

8. Appropriate Client representatives will attend status meetings as required.

9. Project issues will be resolved by management in a timely manner to maintain alignment with the project timeline. A weekly executive team review and discussion meeting will take place to facilitate this.

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Appendix

Q. How will the integration of Business Process Modeling software and enterprise social platforms be used in the NTP to realize the true promise of social testing?

A. The NTP BPM is designed specifically to address task-based work requirements for testing the healthcare lifecycle. This fosters stronger definitions about how to complete a set of required testing activities to produce the desired outcomes and meet the expected results. A core concept of BPM is the idea of building a complete testing workflow. The testing workflow means that completing a testing stream requires multiple deliverables and handoffs between two or more people and/or entities in an organized fashion. Once one entity finishes working on a testing task, the next entity downstream automatically receives the work until the test case is completed. The "management" part of BPM ensures that work is flowing as planned and that individuals are contributing as needed and stakeholders can see and measure performance.

When the social aspect is added to our testing BPM, ICD-10 testing teams are able to collaborate and share information, but they are also able to create a structured path to a business testing outcome, whether that is a decision or the completion of a testing stream. Adding BPM to social takes decision-oriented collaboration and adds workflow with tasks and assignments, sets deadlines and escalations, and looks at the performance of the team. As social integrates with BPM over time, enterprises can see which teams worked well together, which decisions were effective, how long it takes to do the work, and what the overall business value and cost of the activities were. "Work social" means that your time in collaboration has a business value attached to it. It means that the collaborative work is absorbed into your

existing set of tasks. If a worker becomes overwhelmed, concrete data allows work to be reassigned if necessary. An enterprise testing socially has a much better chance of understanding the value of collaboration because it is measurable.

Q. What is the role of mobility in this integrated environment of BPM and social?

A. With mobility, two elements in particular are really important. One is the idea that there may be the need for an employee to work anywhere at any time, and it makes sense to use a mobile device for that purpose. That means the device needs embedded applications that support how the work is managed. The second element is the need to collaborate and work as a team even on a mobile device. With the healthcare industry so diverse we need to provide multiple interaction points to improve communication, coordination and task management.