5010 Implementation - HIMSS
5/2/2011
5010 Implementation: Beyond the Code: The Process, The People, and The Payer Joe Miller, FHIMSS Director of E‐Business AmeriHealth Mercy
Learning Objectives • Understand key 5010/ICD10 risks and value propositions for payers. • Assess how payer strategies will impact you as a provider. • Evaluate opportunities to create win‐win solutions with your payer.
1
5/2/2011
What We Will Cover • • • •
Your 5010 Plan Current Status of Industry 5010 Efforts f d ff 5010 Testing – The Next Challenge 5010 Implementation
Navigating the HIT Perfect Storm: 2010 to 2015 2010
2011
2012
2013
2014
2015
5010 ICD-10 Insurance Eligibility/Claims g y Health Reform Exchanges ERA/EFT Operating Rules and Enrollment et al Exchanges Stage 1
HITECH
Stage 2 © 2007 by the Healthcare Information and Management
Stage 4 3
2
5/2/2011
Payer Risks and Value Proposition for 5010 Payers want as smooth a transition as possible Like providers, payers have a lot on their plate For some payers, 5010 is a simple upgrade For other payers, 5010 has allowed them to significantly enhance their EDI transaction infrastructure • The greatest risk for payers – delay in implementation. • • • •
Five Steps to 5010 Success 1. Plan
• Understand Changes • Assess Gaps • Identify Impacted Systems • Identify key processes and business rules
2. Upgrade / Replace System
• Identify Systems Impacted •Consult Vendor on 5010 Ready Version • Make Chgs for home grown applications • Determine timeline, resources and requirements for upgrade • Internal testing
3. Make Data/ Business Changes
• NPI Changes • Billing Provider Change • Zip Code Change • Account for key business rules • Test business changes internally • Other
4. Conduct External Testing
• What to test • Who to test with (which clearinghouses, payers, vendors) • When to test
5.Implemen t with Trading Partners
• Readiness Checklist • Determine clearinghouse, payer readiness • Production testing? • Contingency Planning • Go Live • Post Post--Implementation Monitoring
Key Resources (See Resource page on GetReady5010.org) GetReady5010 Primer Webinar 5010 Timeline – Getting the Work Done Errrata – What it Means
GetReady5010 Testing Prep Webinar
GetReady5010 Primer Webinar WEDI 5010 Changes That Can be Made Now
GetReady5010 Testing Prep Webinar WEDI Testing Whitepaper CMS MAC Testing
GetReady5010 Testing Prep Webinar Preventing Cash Flow Interruptions
3
5/2/2011
GetReady5010.org
GetReady5010 Sponsors
These sponsors gratefully acknowledge the participation and support of CMS in this Version 5010 educational effort.
4
5/2/2011
5010 Test Education Week Webinars • 5010 Planning – 5010 Primer 5010 Primer – Preparing for Testing
• 5010 Testing
All Webinar recordings and slide decks accessible through GetReady5010.org
– Practices – Large Practices \ Facilities – Medicare Fee for Service – Clearinghouses – Commercial Payers
Huge Response
5
5/2/2011
Payers And 5010 Changes Data Changes • NPI Changes NPI Ch – Notify all payers of any changes
• Billing Provider Changes
Format Changes • Virtually all payers will reject transactions that are not in the new format
– Some payers may edit for this – Don’t need to notify payers of changes to this – Payers use provider db
• 9 Digit Zip Code Changes – Some may edit for this
• Make Your Changes Now! – All changes can work with 4010
Have a specific 5010 project with staffing and resources identified December 2010
12% 29%
26%
13% 20%
May 2010
6
5/2/2011
Providers Approaches to Achieve 5010 Compliance 66%
Upgrade pg Use Clearinghouse Replace
19% 8%
Replace for MU MU* 8%
Don’t Know
16%
Obstacles for 5010 Testing
Payers Not Ready Competition for Resources Vendors Not Ready Clearinghouses Not Ready
67% 53% 50% 47%
7
5/2/2011
Competing Initiatives
66%
EHR Meaningful Use 56%
Other Tech. Projects Business Initiatives External Pressures – Fed/State Regulatory
40% 35%
Calculus for Problems Most Complex Solution – Upgrade (66%) + Competition for Resources (53%) + Delays in Test Scheduling (46%) =
Inadequate Testing
8
5/2/2011
Payer Provider Win‐Win • Many organizations have lost their 4010 expertise ti • Payer and provider expectations for testing need to be aligned • Alignment results in: – Proper level of testing Proper level of testing – Resources used efficiently – Reduction in “worst fears” on both sides
Testing for 5010 Depends on Connectivity Direct Direct Submission
Payer A
PMS Vendor
Provider
Payer B Clearinghouse (A) Payer C Clearinghouse (B)
9
5/2/2011
Types of Trading Partner Testing • Direct Trading Partner Testing with Payer TTest with the payer that you directly connect to t ith th th t di tl tt No intermediate trading partners involved Recommended for all providers using direct connections Certification required by some trading partners (Medicare) Example: Best Family Practice (provider) uploads claims from their practice management system to Alpha Health p g y p Plan – Note: Providers’ vendor may certify the connection to the payer which will vastly reduce the level of testing required
– – – – –
Types of Trading Partner Testing • Direct Trading Partner Testing with Clearinghouse – TTest with the clearinghouse that you directly connect to t ith th l i h th t di tl tt – No intermediate trading partners, such as other clearinghouses, should be involved – Recommended for all providers – Example: Best Family Practice (provider) uploads claims from their practice management system to Ace Clearinghouse – Note: Providers’ vendor may certify the connection to the payer which will vastly reduce the level of testing required
10
5/2/2011
Types of Trading Partner Testing • Indirect Trading Partner Testing – TTest with the trading partner (clearinghouse or health t ith th t di t ( l i h h lth plan) that you directly connect to thru to the payer – Intermediate trading partners involved – Unlikely to be supported for provider testing – Example: Best Family Practice (provider) uploads claims from their practice management system to “Fastest Clearinghouse” that sends the claims to Alpha Health Plan
Types of Trading Partner Testing • Full “End‐to‐End” Testing – Test with the payer by submitting a claims file (837p/i) and expecting back acknowledgements AND a electronic remittance advice (835) – Test cases are consistent between both transactions – Very few payers will be able to support this type of testing due to challenges in maintaining the test environment
11
5/2/2011
Types of Trading Partner Testing • “Production” Testing – Test with the health plan – May have intermediate trading partners involved – Provider submits a limited set of production claims in 5010 format – Will not be supported by all payers pp y p y
HIMSS Survey Dec 2010: When do you plan to Start Testing with Trading Partners?
Q1
Q2
Q3
Q4
% of Providers Responding 2011 * 4% Indicate they do not plan to test
12
5/2/2011
Payer and Clearinghouse Challenges with Errata Q1
% of Providers Responding
Q2
Q3
Q4
p Errata Prep.
2011 * 4% Indicate they do not plan to test
Payer Implementation • Most Payers will implement far ahead of the January compliance date January 1 compliance date • Direct Connects: Can test, be certified and then switch over. • Specific method to “turn on” 5010 will be determined from payer to payer • Some payers will turn on all a once and allow th i f t d l i h their front end clearinghouses convert over t individual providers – Risk: Providers that have not made the data changes could be at risk. ©2010 Healthcare Information and Management Systems Society
13
5/2/2011
Payer Concerns • Most providers will wait until the last minute t t t to test • Demand for payer support with issues and questions will exceed payer ability to respond • Providers will be come frustrated, implement poorly with little testing or drop to paper poorly with little testing or drop to paper • 5010 delays will impact ICD‐10 implementation
Impact of Inadequate Testing
The
Remediate
Test Externally
Plan
Test Internally
And
Remediate
THE REALITY!
And Test Internally
and Implement
Test Externall y and Impleme nt
2012
2013
ICD‐10
Stabilize
2011 Stabilize
2010
ICD‐10
14
5/2/2011
5010 Exit 242
Don’t Get Caught In the Traffic Jam • • • •
Make 5010 DATA Changes NOW g Test 5010 DATA and FORMAT as Soon As You Can Convert to 5010 Before December 2011 Don’t Wait and Get Caught In Traffic
Affordable Care Act – Section 1104 Operating Rules
Certification of Health Plans
Financial Penalties For Non‐Compliance
15
5/2/2011
Operating Rules ‐ Statute Affordable Care Act Section 1104 HHS Designated Entity to Set Operating Rules for: • Eligibility and Claim Status (1/1/2013) • ERA and EFT (1/1/2014) • Enrollment, payment, authorizations (1/1/2015) Expedited Rulemaking
Operating Rules ‐ Update NCVHS Testimony July NRecommendation Letter to HHS Sept 30 ( h dh \100930lt2 df) (www.ncvhs.dhss.gov\100930lt2.pdf):
• Operating Rule Entities – CAQH/CORE, NCPDP • Use CORE Level II Rules • Enhance if Possible by December 1 • On schedule to meet statutory requirements for p g y y operating rules by July 1, 2011
16
5/2/2011
Certification • Statue: “may designate independent, outside entities to certify” • Certification does not apply to providers pp y p
Penalty • Statue: “the Secretary shall assess a penalty fee (as determined under subparagraph (B)) against a health plan that has failed to meet the requirements under subsection (h) with q ( ) respect to certification and documentation of compliance” • Penalty ‐ $1/member/day up to 20 days a year, can be doubled if plan found to be negligent • Health plan with 1.3m members stands to loose $26m per year or $52m if negligent • No penalties for providers
17
5/2/2011
Questions
? Joe Miller Joe Miller [email protected]
©2010 Healthcare Information and Management Systems Society
18
5010 Implementation: Beyond the Code: The Process, The People, and The Payer Joe Miller, FHIMSS Director of E‐Business AmeriHealth Mercy
Learning Objectives • Understand key 5010/ICD10 risks and value propositions for payers. • Assess how payer strategies will impact you as a provider. • Evaluate opportunities to create win‐win solutions with your payer.
1
5/2/2011
What We Will Cover • • • •
Your 5010 Plan Current Status of Industry 5010 Efforts f d ff 5010 Testing – The Next Challenge 5010 Implementation
Navigating the HIT Perfect Storm: 2010 to 2015 2010
2011
2012
2013
2014
2015
5010 ICD-10 Insurance Eligibility/Claims g y Health Reform Exchanges ERA/EFT Operating Rules and Enrollment et al Exchanges Stage 1
HITECH
Stage 2 © 2007 by the Healthcare Information and Management
Stage 4 3
2
5/2/2011
Payer Risks and Value Proposition for 5010 Payers want as smooth a transition as possible Like providers, payers have a lot on their plate For some payers, 5010 is a simple upgrade For other payers, 5010 has allowed them to significantly enhance their EDI transaction infrastructure • The greatest risk for payers – delay in implementation. • • • •
Five Steps to 5010 Success 1. Plan
• Understand Changes • Assess Gaps • Identify Impacted Systems • Identify key processes and business rules
2. Upgrade / Replace System
• Identify Systems Impacted •Consult Vendor on 5010 Ready Version • Make Chgs for home grown applications • Determine timeline, resources and requirements for upgrade • Internal testing
3. Make Data/ Business Changes
• NPI Changes • Billing Provider Change • Zip Code Change • Account for key business rules • Test business changes internally • Other
4. Conduct External Testing
• What to test • Who to test with (which clearinghouses, payers, vendors) • When to test
5.Implemen t with Trading Partners
• Readiness Checklist • Determine clearinghouse, payer readiness • Production testing? • Contingency Planning • Go Live • Post Post--Implementation Monitoring
Key Resources (See Resource page on GetReady5010.org) GetReady5010 Primer Webinar 5010 Timeline – Getting the Work Done Errrata – What it Means
GetReady5010 Testing Prep Webinar
GetReady5010 Primer Webinar WEDI 5010 Changes That Can be Made Now
GetReady5010 Testing Prep Webinar WEDI Testing Whitepaper CMS MAC Testing
GetReady5010 Testing Prep Webinar Preventing Cash Flow Interruptions
3
5/2/2011
GetReady5010.org
GetReady5010 Sponsors
These sponsors gratefully acknowledge the participation and support of CMS in this Version 5010 educational effort.
4
5/2/2011
5010 Test Education Week Webinars • 5010 Planning – 5010 Primer 5010 Primer – Preparing for Testing
• 5010 Testing
All Webinar recordings and slide decks accessible through GetReady5010.org
– Practices – Large Practices \ Facilities – Medicare Fee for Service – Clearinghouses – Commercial Payers
Huge Response
5
5/2/2011
Payers And 5010 Changes Data Changes • NPI Changes NPI Ch – Notify all payers of any changes
• Billing Provider Changes
Format Changes • Virtually all payers will reject transactions that are not in the new format
– Some payers may edit for this – Don’t need to notify payers of changes to this – Payers use provider db
• 9 Digit Zip Code Changes – Some may edit for this
• Make Your Changes Now! – All changes can work with 4010
Have a specific 5010 project with staffing and resources identified December 2010
12% 29%
26%
13% 20%
May 2010
6
5/2/2011
Providers Approaches to Achieve 5010 Compliance 66%
Upgrade pg Use Clearinghouse Replace
19% 8%
Replace for MU MU* 8%
Don’t Know
16%
Obstacles for 5010 Testing
Payers Not Ready Competition for Resources Vendors Not Ready Clearinghouses Not Ready
67% 53% 50% 47%
7
5/2/2011
Competing Initiatives
66%
EHR Meaningful Use 56%
Other Tech. Projects Business Initiatives External Pressures – Fed/State Regulatory
40% 35%
Calculus for Problems Most Complex Solution – Upgrade (66%) + Competition for Resources (53%) + Delays in Test Scheduling (46%) =
Inadequate Testing
8
5/2/2011
Payer Provider Win‐Win • Many organizations have lost their 4010 expertise ti • Payer and provider expectations for testing need to be aligned • Alignment results in: – Proper level of testing Proper level of testing – Resources used efficiently – Reduction in “worst fears” on both sides
Testing for 5010 Depends on Connectivity Direct Direct Submission
Payer A
PMS Vendor
Provider
Payer B Clearinghouse (A) Payer C Clearinghouse (B)
9
5/2/2011
Types of Trading Partner Testing • Direct Trading Partner Testing with Payer TTest with the payer that you directly connect to t ith th th t di tl tt No intermediate trading partners involved Recommended for all providers using direct connections Certification required by some trading partners (Medicare) Example: Best Family Practice (provider) uploads claims from their practice management system to Alpha Health p g y p Plan – Note: Providers’ vendor may certify the connection to the payer which will vastly reduce the level of testing required
– – – – –
Types of Trading Partner Testing • Direct Trading Partner Testing with Clearinghouse – TTest with the clearinghouse that you directly connect to t ith th l i h th t di tl tt – No intermediate trading partners, such as other clearinghouses, should be involved – Recommended for all providers – Example: Best Family Practice (provider) uploads claims from their practice management system to Ace Clearinghouse – Note: Providers’ vendor may certify the connection to the payer which will vastly reduce the level of testing required
10
5/2/2011
Types of Trading Partner Testing • Indirect Trading Partner Testing – TTest with the trading partner (clearinghouse or health t ith th t di t ( l i h h lth plan) that you directly connect to thru to the payer – Intermediate trading partners involved – Unlikely to be supported for provider testing – Example: Best Family Practice (provider) uploads claims from their practice management system to “Fastest Clearinghouse” that sends the claims to Alpha Health Plan
Types of Trading Partner Testing • Full “End‐to‐End” Testing – Test with the payer by submitting a claims file (837p/i) and expecting back acknowledgements AND a electronic remittance advice (835) – Test cases are consistent between both transactions – Very few payers will be able to support this type of testing due to challenges in maintaining the test environment
11
5/2/2011
Types of Trading Partner Testing • “Production” Testing – Test with the health plan – May have intermediate trading partners involved – Provider submits a limited set of production claims in 5010 format – Will not be supported by all payers pp y p y
HIMSS Survey Dec 2010: When do you plan to Start Testing with Trading Partners?
Q1
Q2
Q3
Q4
% of Providers Responding 2011 * 4% Indicate they do not plan to test
12
5/2/2011
Payer and Clearinghouse Challenges with Errata Q1
% of Providers Responding
Q2
Q3
Q4
p Errata Prep.
2011 * 4% Indicate they do not plan to test
Payer Implementation • Most Payers will implement far ahead of the January compliance date January 1 compliance date • Direct Connects: Can test, be certified and then switch over. • Specific method to “turn on” 5010 will be determined from payer to payer • Some payers will turn on all a once and allow th i f t d l i h their front end clearinghouses convert over t individual providers – Risk: Providers that have not made the data changes could be at risk. ©2010 Healthcare Information and Management Systems Society
13
5/2/2011
Payer Concerns • Most providers will wait until the last minute t t t to test • Demand for payer support with issues and questions will exceed payer ability to respond • Providers will be come frustrated, implement poorly with little testing or drop to paper poorly with little testing or drop to paper • 5010 delays will impact ICD‐10 implementation
Impact of Inadequate Testing
The
Remediate
Test Externally
Plan
Test Internally
And
Remediate
THE REALITY!
And Test Internally
and Implement
Test Externall y and Impleme nt
2012
2013
ICD‐10
Stabilize
2011 Stabilize
2010
ICD‐10
14
5/2/2011
5010 Exit 242
Don’t Get Caught In the Traffic Jam • • • •
Make 5010 DATA Changes NOW g Test 5010 DATA and FORMAT as Soon As You Can Convert to 5010 Before December 2011 Don’t Wait and Get Caught In Traffic
Affordable Care Act – Section 1104 Operating Rules
Certification of Health Plans
Financial Penalties For Non‐Compliance
15
5/2/2011
Operating Rules ‐ Statute Affordable Care Act Section 1104 HHS Designated Entity to Set Operating Rules for: • Eligibility and Claim Status (1/1/2013) • ERA and EFT (1/1/2014) • Enrollment, payment, authorizations (1/1/2015) Expedited Rulemaking
Operating Rules ‐ Update NCVHS Testimony July NRecommendation Letter to HHS Sept 30 ( h dh \100930lt2 df) (www.ncvhs.dhss.gov\100930lt2.pdf):
• Operating Rule Entities – CAQH/CORE, NCPDP • Use CORE Level II Rules • Enhance if Possible by December 1 • On schedule to meet statutory requirements for p g y y operating rules by July 1, 2011
16
5/2/2011
Certification • Statue: “may designate independent, outside entities to certify” • Certification does not apply to providers pp y p
Penalty • Statue: “the Secretary shall assess a penalty fee (as determined under subparagraph (B)) against a health plan that has failed to meet the requirements under subsection (h) with q ( ) respect to certification and documentation of compliance” • Penalty ‐ $1/member/day up to 20 days a year, can be doubled if plan found to be negligent • Health plan with 1.3m members stands to loose $26m per year or $52m if negligent • No penalties for providers
17
5/2/2011
Questions
? Joe Miller Joe Miller [email protected]
©2010 Healthcare Information and Management Systems Society
18
