Massachusetts Health Data Consortium

Securing Prompt and Accurate Reimbursement

Patrice DeVoe

Vice President of Operations

Tufts Health Plan

December 13, 2012

1

DRAFT Session Objectives

Provide you with an overview of Tufts Health Plan ICD-10 Program

Describe our approach to testing

Share what we are planning on our outreach to providers

2

Tufts Health Plan’s ICD-10 Program: Major Work Threads

3

Work Thread Descriptions

External Readiness

Manage vendors and vendor solution impacted by ICD-10 implementation

Evaluate provider readiness and implementation of any training and/or education of ICD-10 to the

providers and/or other external parties

Conceptual Design Illustrate how all the components of the proposed system architecture will work together as part of the

overall ICD-10 solution

Code Mapping Translate the ICD-9 codes and descriptions found in Tufts Health Plan’s business manuals, policies,

job-aids, etc. into ICD-10 codes and descriptions

Detailed Business

Requirements Identify detailed business requirements across all departments

Technology Upgrade, modify, and/or enhance the applications that use/process ICD codes and descriptions

Financial Modeling Build and execute models to calculate financial risk associated with ICD-10 in an iterative fashion

Business

Readiness and

Training

Prepare internal business areas for ICD-10 transition, including policy development, workflow

remediation, business remediation, and configuration

Support the development of training tools and communications

Testing

Integrated System Testing (IT Testing): Focus on testing the technology (application) changes to

support ICD-10 and make sure the application is stable and ready for Business testing

Business Testing: Focus on test planning and test execution across multiple testing phases

Deployment Coordinate activities to prepare and support the organization to enable a successful implementation

Tufts Health Plan has structured a comprehensive implementation program, consisting of various

work threads operating together through this multi-year preparation of ICD-10 transition

Tufts Health Plan’s ICD-10 Program: High Level Roadmap

4

2010 2011 2012 2013 2014

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

External Readiness

Conceptual Design

Code Mapping

Detailed Business Requirements

Technology

Financial Modeling

Business Readiness and

Training

Testing

Deployment

Pilot

We are here Go-live

Tufts Health Plan started planning early for the ICD-10 transition, and focused on understanding the

business impact of ICD-10 through requirements sessions while remediating the technology

Understanding the highest areas of business impact helped Tufts Health Plan prioritize the work

Extracts

Tufts Health Plan’s ICD-10 Program: Code Mapping Approach

5

Gather Artifacts Translate ICD-9 to ICD-10

codes and descriptions Remediate Artifacts Maintenance Process

• Gather and document all the

policies, job aids, manuals

and internal documents that

currently contain ICD-9 codes

and descriptions

• Utilizing multiple channels of

communications; new

artifacts and updates to

existing artifacts will be

identified

• Using the Forward Mapping

GEMs and the reverse look-

up as a guideline develop the

base map of ICD-9 to ICD-10

codes and descriptions

• Understand the intent and

business use of the artifact

that contains ICD-9 code

• Determine which ICD-10

codes from the base map are

applicable to use in each of

the artifacts

• Reports drawn from the

database will be used for

artifact remediation

• Artifacts will need to be

remediated (by the Business)

based on the mappings with

the approval of the Business

Artifact owners

• The Business Readiness

Team will oversee these

updates

• In the interim period until go-

live in 2014, a process is

needed to keep the Code

Mapping Team and Business

Areas appraised of any

artifact updates or new

artifacts

• The Code Mapping Team will

monitor newly released codes

and review artifacts for

impact

2 1 3 4

Understanding the clinical intent of various business rules and artifacts helps to maintain business

operations in the ICD-10 world, and keep the intent of the codes the same

Tufts Health Plan’s ICD-10 Program: Deployment Approach

6

We will be phasing our deployment of ICD-10 ready systems and business functionality with an intent

to have functions across the organization ICD-10 ready and knowledgeable well in advance of the

compliance date

Phase 1: Remediate, Test and Deploy

Technology Changes

Phase 2: Remediate, Test and Deploy

Business Configuration Changes

Phase 3: Business starts to review and maintain

ICD-10 codes along with the ICD-9 codes

Compliance Date: October 1, 2014

Prior to the

Compliance Date

On & Post

Compliance Date Accept and Process ICD-10 Codes

Tufts Health Plan’s ICD-10 Program: High Level Integrated Testing Lifecycle

7

ICD-10 testing focuses on touch points with internal and external entities

Training

THP ICD-10

Program

Business Rules

&

Code Mapping

Business

Processes

Providers

System

Changes

Vendors

Policies

Business

&

Trading

Partners

Significant and comprehenisve business testing efforts are required due to the scope of ICD-10

Internal

External

Tufts Health Plan’s ICD-10 Program: Summary of Test Phases

8

Application

Unit Test Test individual components as code is developed

Integration

System Test

Ensures that system components, individually and collectively, are certified before the

application is connected or integrated with other existing or new applications

Performed as a stand-alone entity and includes integration as appropriate

Perform Vendor software testing and Trading Partner system testing as appropriate

Performance

Test Test the module under different stress conditions to ensure the system keeps performance at

the levels outlined in the requirements

User

Acceptance

Test (System)

Test integration/performance validated modules and verify the business function and flow of

the system

Conducted by day-to-day business users

Test Phase Purpose

Functional

Parallel Test

External testing with providers on coding behavior and transactions

Perform Vendor software testing and Trading Partner testing as appropriate

Dev

Test

QM

S

Test

Bu

sin

ess

Test

Pro

du

cti

on

Test

Critical Success Factors

Components are tested

before being deployed

QMS reviews results and

accepts code

Integrated testing of

technology components

Regression testing

occurs between builds

Code is stable

Business resources are

available

Business artifacts are

finalized and utilized

during testing process

Test case prioritization

scheme defined

Test entry/exit criteria

established

Test schedules are

aligned

Automate where

possible

Code is stable

SLAs are received and

benchmarked against

(performance specific)

A dedicated core team is

available for triage

(parallel specific)

Configuration

Test Test configuration components as they are setup. (Benefit Configuration, etc)

Unit testing of configured components

Tech

nic

al

Fo

cu

s

Ris

k B

ased

Bu

sin

ess F

oc

us

R

ead

ine

ss F

oc

us

Degree of functional

coverage

Test entry/exit criteria

established

Model Office Verify processes that have significantly changed Verify alignment of manual processes outlined in the future state workflows to their

corresponding system interactions

E2E

Test Verify end-to-end system processing including key business rules testing of automated

processes; Conducted by program SMEs

ICD-10 testing allows to identify anomalies in the process and systems, and mitigate for the future

Provider/

External

Test

Simulating multiple rounds of key production processes with live production data (e.g. check

run) to ensure that no additional discrepancies are discovered

Tufts Health Plan’s ICD-10 Risk-Based Testing Approach

9

Risk-Based Testing Phases

Time & Maturity

Integrated System

Testing

Vo

lum

e &

Co

ve

rag

e o

f R

isk

Oct 2014

Provider

Testing

Production

Operation

Monitoring

End-to-End

Testing

Focus on validating

technical changes,

including traditional

testing phases.

Includes: Unit and

System Testing

Focus on

validation of

interconnected

end-to-end

business

changes.

Focus on

validating

financial

outcomes

based on

provider-

coded

transactions

Traditional Focus for

Health Plan Testing

Focus on

validating

financial

outcomes

based on

provider-

coded

transactions

Focus on

validating

external

partners’

readiness for

ICD-10

transition

Financial Modeling

Functional

Parallel Testing

Focus on

validating

technical changes

and financial

outcomes based

on manufactured

data

Configuration

Testing

Focus on

validation of

business

configuration

changes.

ICD-10 Testing demonstrates the impact of financial and operational outcomes, while continuing to

validate system reliability with more production-like data permutations

Provider Collaboration

External

Testing

Tufts Health Plan’s External ICD-10 Testing Objectives

10

3. Software

Vendors

4. Service

Vendors

2.Employer

Groups

1. Business

Partners

• Establish enterprise wide vendor governance and manage external testing partners throughout the ICD-10 program

• Coordinate with external partners to determine ICD-10 remediation requirements and testing plan

• Execute external party testing based on predefined plan

• Develop a mitigation plan for external partners that are ‘at risk’ to Tufts Health Plan’s ICD-10 implementation plan

External Testing Objectives

External Testing Partners

1. Partners that Tufts

Health Plan has an

exclusive relationship

with from a claims pricing

perspective

3. Vendors that Tufts

Health Plan uses a

software package from

4. Vendors that contract

with Tufts Health Plan

where information is sent

to the vendor to perform

a specific service

2. Employer groups that

Tufts Health Plans either

exchanges data (e.g.

extracts or reports) or

shares a business

process

Tufts Health

Plan

External testing assesses external partners’ plans to be ICD-10 compliant, and how they align with

Tufts Health Plan’s ICD-10 implementation

Provider Collaboration vs. Provider Testing

Provider Testing and Provider Collaboration will be important in order to prepare both Tufts

Health Plan and the providers for the ICD-10 transition

Provider

Collaboration

Provider Collaboration involves reaching out to a target group of providers in order to plan

for the ICD-10 transition collaboratively

The effort will require a smaller, select group of providers

The process will begin earlier in the ICD-10 transition timeline and deal with more broad,

complex issues

Provider

Testing

Provider Testing involves reaching out to providers in order to make sure that system

remediation is complete for ICD-10

The effort will involve a larger number of providers

The process will take place later in the ICD-10 transition timeline and be a more

standard, iterative process to make sure mappings will be valid on the transition date

Live / Post

Deployment

Providers and Tufts

Health Plan

collaboratively perform

analysis of overall

results including

financial impacts and

reach consensus on

mitigation strategies

Tufts Health Plan

adjudicates and

provides output

in an agreed

upon format

Providers code

medical condition as both

ICD-9 and ICD-10 claims in

an agreed upon format

Our expectation from the Provider Collaboration/Provider Testing would be . . .

DRAFT Tufts Health PlanICD-10 Business Testing Timeline

ICD-10 Business Testing will incorporate more scope than the traditional phases of testing

2012 2013 2014

Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

IST Testing

Detailed Test Plan & Preparation

E2E Testing

UAT Testing

Functional Parallel /

Financial Neutrality Testing

External Testing

Model Office

Technical Parallel Testing

Wave 1: Technical Integrity Testing

Wave 2: Business Integrity Testing

Wave 3: Financial Neutrality Testing

Key

Functional Parallel

Test Plan & Preparation

DRAFT Early Payor / Provider Discussions

Prior to Go-Live:

Assess ICD-10 impact to our contracts and payments

Model the updated groupers and contract terms

Start early reach out and communications with our providers

Publish medical, payment, and other associated policies in advance of the

compliance date

Deployment and Post Go-Live:

Monitor key performance indicators and other benchmarks to track the timely

processing of authorizations, referrals, servicing, and claims

13

Goal of both our internal as well as external testing efforts is to prepare our business for

operating in ICD-10 and not impact timeliness and accuracy of our claim payments