Boards May 4-‐8, 2015
9:00 a.m. to 3:30 -‐ 4:00 p.m.
I. Organizational Preparedness: What You Need to Know and Do
Background
Systems and Business Processes Vendors and External Systems Contracting and Payers
Testing, Revenue, and Training
II. Organizational Tools for Your Team
III. Desk Reference Materials
Lisette Wright, M.A., Licensed Psychologist Executive Director
Behavioral Health Solutions
BEHAVIORAL HEALTH/SUBSTANCE USE
PROVIDER ORGANIZATIONS
Prepared exclusively for: Fairfax County and Health Planning Region II Community Service Boards
By:
Behavioral Health SoluOons, P.A.
LiseRe Wright, M.A., Licensed Psychologist ExecuOve Director
May 4-‐8, 2015
Agenda
OrganizaOonal Readiness
Systems and Business Process Inventory
Revenue Cycle and Billing
ContracOng and RelaOonships
TesOng
READINESS
Typical ICD-‐10 TransiOon QuesOons
What are we going to do?
Who’s going to do it?
When is this going to get done?
How long will it take?
How do we know WHAT to do?
ICD-‐10 ImplementaOon In Steps
1.
ExisOng Culture and A\tudes
2.
Internal Team/CommiRee’s
3.
Assessment of Current States
4.
Planning and ExecuOng the Tasks
5.
Assessing and Tracking the Progress
ICD-‐10 Components
“What’s
YOUR
Y2K
Plan?”
Desk Reference Materials Clinical Training / EducaOon Revenue Cycle Systems & Business Processes Payer Contracts Policies and Procedures CDI ProgramExisOng Culture And A\tudes
DocumentaOon Compliance
Ownership and Steward of Quality
Care
SupporOng the DX and TP throughout
the LOS
EHR A\tudes Reinforcing the Leadership: Need to Change
Concept of ProacOve Versus
ReacOve All it takes is 1
lawsuit, suicide, payback…
Aligning With Strategy
Vision and Mission Focused
Consumer-‐centric and HolisOc Collegial and
Internal Team Membership
Clinical Medical Billing/Revenue Cycle Leadership Quality/ComplianceChampions of PosiOve Change InformaOon or ApplicaOons Systems
Sharing The Work Load And Strategy
• Core ICD-‐10 ImplementaOon Team
• Programs: May have smaller teams of 2-‐3 people
• At this point, meet weekly
• Use internal communicaOons such as SharePoint
• Keep straighjorward minutes:
1. Describe the Problem
2. The AcOon Item
3. Who Assigned To
What Do We Do?
q
Communicate with all stakeholders
q
Establish sequence, Oming, and work effort needed
q
Assess, idenOfy, and facilitate remediaOon plans
q
Inventory and assign tasks, to-‐do’s, and Omelines
q
Liaison between parOes (staff, management, 3
rdparOes)
q
IdenOfy & problem-‐solve risks to ICD-‐10 project execuOon
q
IdenOfy decision-‐making authority and processes
q
Provide mechanism for stakeholder feedback and input
PROCESS INVENTORY
Systems And Business Processes
We know what we currently do…
We know where we must be…
The Systems And Business Process Inventory
Examples Of Systems
DiagnosOc touchpoints Any Stand-‐Alone Databases kept for OperaOonal Purposes Eligibility and Benefit InformaOon Systems Prior-‐ AuthorizaOon’s, Forms PracOce Management Systems, eRX, HIE’s, Labs ReporOng: Public health, state, performance Child Welfare or other regulatory systems Super bills, charge sheets, MD visits, OON Forms Claims and Clearinghouses Computerized conversion tools (ICD-‐DSM) EHR’s: internal logic of CDS, alerts Business Intelligence / AnalyOcs ReporOng Internal databases / registries Templates EHR Billing RulesHow To Perform A Systems Inventory
1. Make a list of the system and any subsystem
2. Determine what is affected and what changes need to happen
3. Determine Omelines (internal and external)
4. IdenOfy and track contacts, bulleOns, updates, dates, etc.
5. IdenOfy other tasks necessary to make the system work
Helpful Framework For Systems
• Think about workflows and who does what:
• Who Assigns Diagnoses?
• Who submits claims?
• What paperwork do you use?
• Where does this paperwork live?
• Who performs eligibility checks?
• How do mulOple, different diagnoses apply to 1 consumer and who
determines this?
• Who assigns diagnoses? What if there are concerns or quesOons?
• Is there a way to streamline the process?
Systems QuesOons To Ask Vendors
• Vendors and Other Outside Business Associates
• Plan, Dates, and Timelines
• TesOng
• Releases or Updates and Cost
• What training will you provide on the new diagnoses in the system
• Customer Support for Problems/TroubleshooOng
• UOlizaOon of dual-‐coding, back-‐billing
• Results of tesOng with payers
• Source of Codes?
• Vendor percepOon of impact on workflow?
The EHR: A Major Area For Concern
Your EHR
contains
diagnosOc
informaOon
is “hidden”
places
Your EHR
Vendor may
not be
ready, or
have
“turned on”
the
funcOonality
The
funcOonality
provided
may not be
User
Friendly
Three Main Areas Of EHR FuncOonality
Code Set Maintenance: What is the vendors plan to keep up with the CDC ICD-‐10 CoordinaOon and Maintenance changes; Who maintains the table structure modificaOons?
Code Set “AggregaOon”: Are the codes grouped according to diagnosOc category? If YES, then who does this?
ICD And DSM In The EHR
• Proprietary processes: How one vendor does it is how one vendor does it
• Easier to load ICD-‐10 codes into the system
• DSM: Licensing Fees hi\ng vendors hard (6-‐figures)
• Some vendors sOll do not have DSM-‐5 codes loaded
• Netsmart:
• Plug in DSM-‐5 diagnosis name, ICD-‐10 codes are then suggested
• Qualifacts:
• Same strategy as Netsmart
• EPIC: DSM? What’s That? Sure, we will add it!
DSM-‐5 In EHR’s: What They Are Doing
Huh? Mixing ICD 9-‐10 codes with DSM-‐5 “descripOons?” Then again, if this works…
Again, how one vendor does it is one way. No
standardizaOon, no consensus, direcOon, guidance, etc. Therefore, the burden is on you as a provider
DSM-‐5
• Using the Axis III field to represent the main ICD-‐10 diagnosis
• Some drop downs only contain the frequently used codes
• Not all codes needed are included
• Self-‐Harm Codes
• Co-‐morbid Medical codes
• Including/not WHODAS
• Take-‐Away From the Vendor ConversaOons:
• The vendors are in the same boat that we are!
• Every vendor is different
• Main message: Burden is on the provider organizaOon to work through
Some Possible OpOons For Code Searches
• Term-‐Based:
• Using one word, or part of a word to produce the diagnosis lisOng
• Search By Code
• Search by code range, individual code numbers, parOal code numbers
• AlphabeOcal or Tabular-‐Based:
• Search by the 2015 Tabular Index or AlphabeOcal Index
• Concept-‐Based:
• Similar to Term-‐Based, but pulls tables from clinical concepts such as
“depression” or “anxiety”
• Crosswalks:
• Search by the old ICD-‐9 code with results pulling ICD-‐10 suggesOons
Advanced: Code AggregaOon
• Groups/Categories of Codes that are used to support analyOcs and business intelligence (similar to a data dicOonary concept)
• To do this, you will need:
1. A standardized name for the set of codes 2. DefiniOon of the intent of the code set
3. DescripOon of what codes are aggregated and why 4. Unique idenOfier for the set
Your EHR Diagnosing To-‐Do’s
1. Clinical: drop-‐down’s, language and terms
2. Assess for dual-‐coding capability before/auer October 1 AND is it End-‐User determined?
3. Diagnoses in the System:
a. At the Program or Service Level?
b. Who changes these pre/post October ?
c. When will the diagnoses change prior to October 1?
d. How does this get changed so data entry only happens once for the
clinician?
e. Diagnosis Tables: How do they funcOon? Does the end user pick ICD
versus DSM? If it is pre-‐set, what about pre-‐October 1 diagnoses? Axis versus No Axis's?
Diagnosing ConOnued…..
7. Specifier pop-‐up windows? For ICD or DSM?
8. FuncOonal Assessments: GAF, WHODAS and the ability to
combine the GAF without Axis-‐driven diagnosing 9. MulOple providers for one consumer: How does the
diagnosis get managed?
EHR Items
Billing Rules Supports or Internal Clinical Decision Logic
Templates and Clinical
DocumentaOon Support Tools
Reports: May need to be modified or new
ones created
Imports and Exports: Transfer of care from somewhere else and
imporOng DX’s (HIE)
Custom Forms
Order Sets? Can you add prompts in the EHR to capture good documentaOon?
Vendor-‐Partnership
§ Acknowledge their struggle
§ Offer to be a Beta-‐site to get ahead of improvements
§ Work closely with the Vendor to request improvements:
§ Increased support at go-‐live?
§ Expected response Omes?
§ Vendor readiness for the federally mandated changes?
§ RemediaOon plans
§ Penalty plans
§ Any provisions to handle situaOons where vendors do not meet
OperaOonal Processes
How are outside records handled and put into the system? What
about “old” diagnoses?
When do you update current diagnoses and current client records? Conduct Formal Form Review Process: Hunt, gather, slice, dice, update, and improve
Business Processes To Assess And Address
• Referrals
• AuthorizaOons and Pre-‐CerOficaOons
• Payer-‐readiness with the new forms, eligibility systems
• Intake Paperwork for Consumers
• Update forms
• ContracOng ConsideraOons with Vendors and Payers (next secOon)
• Financial OperaOons (see next secOon)
• Clinical training
• Clinical DocumentaOon
• Interfaces and Cross-‐System Dependencies (eRX, HIE)
• ReporOng: Map flow of data/reports and modificaOons needed
BILLING
Biggest Risk And Impact Area
Business Process, Contracts, Issues
Revenue and Billing Systems, Claims
Moving Into The Revenue Cycle
•
We will have MORE diagnoses to choose from as of
October 1, 2015, this will require:
ü Assignment of the most specific code/diagnoses
ü More documentaOon to differenOate between diagnoses
ü More documentaOon to support diagnoses (to avoid audit paybacks later)
ü More documentaOon to support medical necessity
What impact will increased specificity and more diagnoses have on contracts and reimbursements?
The Payers Are Busy Too
1. Distribute informaOon and guidelines
2. EducaOon and communicaOon with providers
3. Internal/external tesOng to accept ICD-‐10 claims
4. Review current benefit plans to idenOfy which ICD-‐10 codes match/apply
5. EducaOon of staff (customer service, claims reviewers) 6. Assess and ready for new business processes
7. DSM/ICD Decisions and UOlizaOons
8. Support dual processing (for old DOS requiring ICD-‐9 and new ICD-‐10)
Some Of Their To-‐Do’s
• AdjudicaOon
• Backwards mapping from ICD-‐10 to ICD-‐9
• ContracOng
• Systems upgrades, changes, programming
• BH Carve-‐Outs
• NavigaOng MulO-‐Payer Claims
• Prior-‐authorizaOons and referrals
• Claim edits
• Policies
• Formularies
Every other healthcare provider they offer services to will also be in line
Payers: Are Challenged As Well
• Samples
• #1: Magellans website
Payers: Who Is Doing What When?
• Everyone is doing something different at different Omes:
18 payer sources = 18 different Mmelines
What Does All This Mean?
• Expect changes mid-‐stream and flip-‐flops
• We are entering a whole new era that will demand:
ü Accountability, Specificity
ü Demonstrable Progress and Concrete Outcomes
ü Medical Necessity thresholds increasing for our industry
ü DocumentaOon like we have never seen it before
ü Pay For Performance and Outcomes ONLY
ü MedicalizaOon of our industry
ü CoordinaOon of Care
ü An enOre culture shiu in thinking about how we treat individuals with
Contracts With Payers
• Review your contract and accompanying fee schedule for any potenOal issues
• Are you reimbursed based on CPT or diagnosis codes?
• Look for words like:
• Reimbursement formulas
• Usual and customary
• Fee Schedules – may be aXached separately from the actual contract
• Covered/Not Covered Diagnoses
• Language regarding ICD/DSM
Payer Contracts: What To Ask Them
• Do you plan to change your reimbursement rates or fee
schedule for ICD-‐10 diagnosis codes?
• What impact will ICD-‐10 have on coverage policies?
• Do you plan to re-‐negoMate your contracts for ICD-‐10?
• Are you going to re-‐negoMate the contracts when they are up
for renewal or prior to that date?
• What impact, if any, will ICD-‐10 have on our fee schedule?
• What impact will ICD-‐10 have on your medical review, audiMng,
and coverage?
• Are there addiMonal diagnoses that you can get paid for?? (i.e.:
Internal ConsideraOons And QuesOons
1.
How many payers do you have and what is their
respecOve revenue percentage?
2.
What pre-‐exisOng claims problems have had with
any parOcular payer? What have your claim denial
rates been with them in the past?
3.
How have they resolved claims problems in the past?
4.
What is your Plan B for any parOcular party and how
big will the “hit” be?
5.
Have contact informaOon: Phone numbers,
instrucOons, name of person handy
Your To-‐Do’s Regarding Payers
• Give thought to asking the Payer how they will compensate you should a delay occur?
• Have they made arrangements for interim payments if delays become unreasonable?
• Consider requiring interim payments subject to retroacOve reconciliaOon if operaOons appear to be affected—pull out your contract and see what leverage you may have
• Appeals, or requests for reviews, will be your burden (Ome, cost) not unlike it is now
• Recognize that you will get conflicOng, erroneous, and misleading informaOon from the Payer and their Provider Service Department
Assessing Internal Revenue Cycle Processes
• Who determines the diagnosis code for the claim?
• Best if the clinician does, not the billing office, administraOve assistant or
other 3rd party; CerOfied Coders are the excepOon
• Does the clinical documentaOon system provide the necessary
informaOon needed to code the diagnosis to the greatest level of detail?
• What plans are in place to improve clinical documentaOon and
support the new, more specific diagnosis?
Inside The Billing Office: Denial RemediaOon
•
Items to Address:
• Analyze root cause of current denials and address process gaps
• Improve pre-‐service CerOficaOon and AuthorizaOon requirements
• Access to contracOng and payer manual updates around Pre-‐CerOficaOon
and AuthorizaOon rules
• Items to Have Ready:
• Track claim payment delays and resubmissions
• Have contact informaOon: Phone numbers, instrucOons, name of person
handy
• Establish a process of how denied claims get handled
• May need 1-‐2 FTE’s the first 4-‐6 months for this to expedite claim denial
Audit-‐Based Reimbursement Recovery
• Tracking how things are going
• Significant disrupOon in clinical documentaOon habits
• New clinical documentaOon requirements will increase audit-‐ failure rates if the documentaOon does not support the ICD-‐10 diagnosis
• IF audits reveal a violaOon of the Clinical Coding and
DocumentaOon Requirements, then we have a problem!
• That said, there is an industry understanding this will be a
Managing Payers
•
Track tests, Omelines, payer issues & remediaOon
steps
•
Realize a manual, Ome-‐consuming review of denial
reasons and resubmissions will be the worst in the
first couple of months (thus the noOon of 1 FTE)
•Determine effecOveness
•
Communicate needs with partners
•
Determine impact to revenue, including changes to
Every single system that holds, transmits, or analyzes
health data will need to be modified and tested
• CMS on TesOng: “TesMng will ensure ICD-‐10 compliance across
internal policies, processes, and systems, as well as external trading partners and vendors”
• Without thorough internal and external tesOng, you will have no idea
if you will be ready or what will happen to your revenue income auer October 1, 2015
• Two Key Factors:
• a) Can you connect AND exchange ICD-‐10 informaOon?
• b) Can the payer handle, adjudicate, and process the claim
correctly?
TesOng And Risk MiOgaOon Strategies
Test
representaOve sample
Use different code combinaOons (SU/
BH/primary-‐ secondary dx’s)
Emphasize tesOng with large pay
source Test different
provider types (MD, aide, etc.)
Test per diems, bundles, individual
CPTs, etc.
Waterfall/ crossover billing
Ensure YOU can test (some restricOons here)
IncorporaOng the DSM in the system
CMS And “End-‐to-‐End” TesOng
• CMS has run a series of tests to assess the state of readiness in the industry: Sample claims submissions to see how they are processed and adjudicated
• So far, the results are encouraging:
• 81% of the claims were processed without problems
• 3% were denied for having an ICD-‐9 code on them
• 3% were denied for being an invalid submission of a ICD-‐10 diagnosis or
procedure
• 13% were denied because folks could not figure out how to set up the
test claims
• What we don’t know: how many of these orgs were in our industry?
Lessons Learned From End-‐to-‐End TesOng
Providers are confused about when to use ICD-‐9 codes versus ICD-‐10 codes on claims
Providers are not using the correct ICD-‐10 codes, possibly due to using insufficient diagnosis coding resources or uOlizing resources that contain errors in them
There is a high likelihood that you will experience some
percentage of rejected claims auer October 1, 2015 and the denial reasons will be numerous
Final Revenue Cycle Thoughts
• How will the new ICD-‐10 codes align with exisOng contracts and reimbursements, billing and coordinaOon of benefits
• How will the new codes affect consumers?
• Eligibility and uOlizaOon management: Eligibility terms will need to be configured, medical necessity, policy checks and associated protocols will have to be updated to uOlize ICD-‐10 codes
• Eliminate any “backlogs” prior to October 1, 2015
• Quickly idenOfy enOOes with high rates of denials or rejecOons
• Quickly idenOfy systems funcOonality problems brought to your aRenOon
The Rule
Claims for services provided on or aaer
October 1, 2015 must use ICD-‐10-‐CM
for diagnoses
CMS will not allow for any grace
period or extension. Non-‐compliant
claims will be rejected and will need to
Staff Training ConsideraOons
Who, What,
When
Onboarding New
Staff
Clinical
DocumentaOon
Improvement
Who Needs The Training?
Clinicians/Medical Billing/Revenue Cycle Intake / RegistraOon / Pre-‐CerOficaOon
Compliance/Quality (data collecOon, reporOng, other requirements)
What is a Mouse? How do I…..???
Pre-‐exisOng struggles with diagnosing or
When: Time The Training
• When will dual coding and tesOng begin?
• Recommend training 2-‐4 months prior to tesOng and dual coding start dates (may need to adjust this as we go along)
• All training should be completed by July, 2015
• Allow for peer-‐reviews of processes/documentaOons and diagnosis checks
• Allow Ome for the revenue cycle tesOng feedback loop and to set up remediaOon plans
Steps In Se\ng Up The Training Program
• Gather New Policies & Procedures
• Clinical documentaOon standards, medical necessity, diagnoses manuals
• Curriculum (Generally 3-‐4 Segments/Groupings of Trainings)
• IntroducOon: Include ICD-‐DSM Interface
• Specific Diagnoses
• Clinical DocumentaOon Standards
• Revenue Cycle Department
• Develop and obtain materials (crosswalks, other reference materials)
PracOce: Dual Coding
(clinical and billing)
Peer Chart Reviews
Revise procedures
and be flexible
Diplomacy Regarding CDI
§
Bad habits are hard to change
§
A\tudes interfere with change
§
Prepare your staff and make this a team effort
§
Acknowledge this is disrupOve to workflow
§
Be open to feedback from clinical staff about
what works/does not work
Chart Review Strategies
Random Samples Most Frequent Diagnoses Known Problem Areas AddiOonal / Refresher TrainingDesk Reference Material OpOons
Customized Internal Crosswalk (Excel)
Substance Use Tools
Clinical DiagnosOc Criteria Cheat Sheets
DocumentaOon Tips/Prompts
Other ConsideraOons
Training Groups: Size
Offer opOons for sign-‐up due to vacaOons, etc. YouTube/Video tape TransiOon Basics
Group diagnoses for training (childhood, adult, and substance abuse)
Who needs what? Intake/pre-‐cerOficaOon may need general diagnosis sets while clinical will need specifics
Run a report, extract the 30 most frequently used diagnoses and start with those
Policies And Procedures
• Gather all P & P’s that involve:
• Clinical documentaOon processes
• Diagnosing
• Revenue
• Review, Assess, and Update
• Decide if you want to include DSM/ICD language, Blue Book
What To Include In Your New Policy
• Policy and Scope:
• This secOon should name the state law and licensure requirements for
your facility
• Acknowledge HIPAA, CMS, ICD and DSM enOOes
• Purpose of Policy
• Specifically outline your intent here for this policy, why it was created
and the intended uOlizaOon
• Key Procedures and Revisions
• Specify how staff will handle the ICD-‐DSM dilemma
• Responsibility
A Final Word…..
Ø This is an opportunity
Ø Improve documentaOon, review processes, standardize
Ø Build cohesiveness and alignment among everyone
Ø Look to your ICD-‐10 TransiOon Team
Ø Realize this is new for everyone
Ø Goals:
Ø Get through this with minimal revenue cycle disrupOon
Ø Improve organizaOonal best pracOces
Clinical Decision Support Logic
Other internal logic in place? HIE eRX Lab Orders Other? Practice Management Software Clearinghouse (s) Business Associates: electronic exchange of info Enrollment/Eligibility/I nsurance Verification Internal Auditing/Compliance Department
Reporting: State, other Public
Health/Syndromic Surveilance
Other Interfaces involving ICD-10 items Any other databases affected?
Metrics or Dashboard Implications
Consumer Portals? List other systems affected below:
claim remits denial reasons timeframe to correct *appeal process/deadline (do not miss these deadlines) Clinical Diagnoses Submission of Diagnoses Documentation Peer Reviews Interface with claims? Policies and Procedures Responsible party Approvals Staff Training Implications Business Intelligence/Metri cs
list subsytems here Front-End
Internal Auditing/Complia nce Department Paper Documentation (Superbills, etc) Business Associates Contracts and Service Level Agreements Intake or front-end procedures Receipt of outside records: management? Updating current diagnoses process Other?
list payers in RANK order and Start with #1 payer, move to #2, etc. Vendor/Payer #1 Vendor/Payer #2 Vendor/Payer #3, etc
Clinical Crosswalks Workflows Dual Coding
Manuals? Approach? Method? Documentation
Medical Crosswalks
Workflows Dual Coding
Manuals? Approach? Method? Documentation
Administrative Intake/Pre-Certification Diangoses Only Workflows
Dual Coding
Manuals? Approach? Method? Documentation
Billing/Revenue Crosswalks Workflows Dual Coding
Manuals? Approach? Method? Documentation
document, track, process Clinical Staff Provide crosswalks, reference
Policy and Procedure decisions approved & communicated? Expectation for dual coding? Expectation for clinical documentation threshold? Claim Denial Processes Who is in charge?
Contact information ready? Appeal and corrected claim Payor Contracts Must Be Reviewed!! Other Items?
EHR Vendor Training Materials collected Vendors Readiness and Timelines
Payers Plans and Timelines
Contract Reviews with both Vendors and Payers Clinical Info/diagnoses
CDI and policies
Risk Mitigation: Id'ng the highest risk areas Testing: Who, When, How
Paper: rewrite superbills,
policies/procedures/other charge-capture Systems Inventory: Who does, by when Denial Processes: Development of a manual or
process
BI/Analytics and Reporting: Who does this/affect?