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					ICD-10 Impacts to the
 Health Care Industry

           Presented by Jim Daley
           HIPAA Project Manager




  Blue Cross Blue Shield of South Carolina
    WHAT ARE THE IMPACTS?
•   Software / Packages
•   Procedures / Treatment
•   Training
•   Forms
•   Reimbursement
•   Statistics
•   Transactions
•   Transition
      Blue Cross Blue Shield of South Carolina
           WHO IS IMPACTED?
•   Payers
•   Providers
•   Vendors
•   Clearinghouses / TPA’s
•   Employers
•   Members
•   Other Business Partners
      Blue Cross Blue Shield of South Carolina
                   837                                                        837
                                                         ICD-10
Transition                                                                           Transactions
  Issues
                  Software
                                             Forms                     Statistics
                                                                                           Tools/
                                                        Procedures                        Packages
 Reimbursement
                              Training

Treatment
 Policies                                                            Providers
                                               Members                                Suppliers
                      Software Vendors



Clearinghouses                                                 Laboratories
                           TPA’s         Insurance Plans
             Blue Cross Blue Shield of South Carolina
                                                                              Employers
                 SOFTWARE
             Payer (In-house Built)
• Changes to
  –   Logic
  –   Screen Maps
  –   Tables / Files
  –   Databases
  –   Reports / Queries
• Extensive Testing

      Blue Cross Blue Shield of South Carolina
                 SOFTWARE
             Payer (In-house Built)
•   Front-End / EDI / Edit
•   Adjudication
•   Authorization / Referral
•   Reimbursement / Capitation
•   Actuarial / Trend Analysis / Rating
•   Utilization / Case Management
•   Customer and Other Reporting
      Blue Cross Blue Shield of South Carolina
                      SOFTWARE
                    Payer (Packaged)
• Groupers
• Edits
  –    Duplicates
  –    Appropriateness of Setting
  –    Medical Necessity
  –    Unbundling
• Length of Stay
• Statistics
• Reference
      Blue Cross Blue Shield of South Carolina
                       SOFTWARE
                       Payer (Other)
• OCR scanning
• VRU or other screen scraping
• Web-based




    Blue Cross Blue Shield of South Carolina
                         SOFTWARE
                           Provider
•   Scheduling
•   Billing
•   Claims Submission
•   Finance / Performance
•   Intensive Care / ER Activity



      Blue Cross Blue Shield of South Carolina
                       SOFTWARE
                         Vendor
• Update software (same types of changes as
  described earlier)
• Update Documentation
• Negotiate with Supported Sites
• Install / Convert / Train



    Blue Cross Blue Shield of South Carolina
                         SOFTWARE
                           Vendor
•   Decision Support Systems
•   Billing / Practice Management
•   Medical Necessity
•   Clinical
•   Managed Care / HEDIS
•   Other Quality Reporting


      Blue Cross Blue Shield of South Carolina
                         SOFTWARE
                           Other
•   Pharmacies
•   Laboratories
•   Clearinghouses
•   Other Service Providers
•   TPA’s
•   Employers / Customers


      Blue Cross Blue Shield of South Carolina
                     PROCEDURES
                        Payer
•   Documentation
•   Hard Copy / Mail Room
•   Error Correction
•   Timeliness
•   Fraud
•   Case Management Policies
•   Reimbursement Policies
•   Underwriting
      Blue Cross Blue Shield of South Carolina
                     PROCEDURES
                       Provider
•   Treatment Policies
•   Authorizations / Referrals
•   Coding
•   Increased Documentation Specificity
•   More Hard Copy



      Blue Cross Blue Shield of South Carolina
                     PROCEDURES
                        Other
•   Clearinghouse
•   TPA
•   Lab
•   Pharmacy
•   Employer
•   Anyone dealing with diagnosis / procedure
    codes.
      Blue Cross Blue Shield of South Carolina
                          TRAINING
                            Payer
•   Claims Processors (Productivity Loss)
•   Administrative
•   I/S
•   Medical Review Staff
•   Reporting
•   Actuaries
•   Auditors
•   Fraud Investigators
      Blue Cross Blue Shield of South Carolina
                           TRAINING
                            Provider
•   Doctors / Nurses
•   Administrative Staff
•   Billing
•   Productivity Losses




      Blue Cross Blue Shield of South Carolina
                           TRAINING
                             Other
•   TPA
•   Lab
•   Employee Benefits Administrators
•   Other Vendors and Service Providers




      Blue Cross Blue Shield of South Carolina
                               FORMS
• Provider Visit Sheets
• HCFA 1500 / 1450
• Other




    Blue Cross Blue Shield of South Carolina
              REIMBURSEMENT
                   Payer
•   Impact to DRG’s
•   Impact to APC’s
•   Impact to line pricing by procedure
•   Contract Negotiations / Fee Schedules
    – Thousands of schedules
• Revise and Distribute Materials
• RBRVS
      Blue Cross Blue Shield of South Carolina
              REIMBURSEMENT
                  Provider
•   Fee Schedules / Contracts
•   New Software
•   Coding Changes
•   Enhanced Documentation
•   Practice Costs / Projections
•   Cash Flow


      Blue Cross Blue Shield of South Carolina
              REIMBURSEMENT
                Other/Member
•   Riders
•   ASO
•   Special Customer Arrangements
•   Coinsurance




      Blue Cross Blue Shield of South Carolina
                     STATISTICS
                    Types of Impacts
•   Trend Analysis
•   Utilization Management
•   Rating
•   Quality of Care / Disease Management
•   HEDIS / Customer Reports
•   Provider Profiling
•   Ad Hoc
      Blue Cross Blue Shield of South Carolina
                       STATISTICS
                      Impacted Areas
•   Payer
•   Provider
•   National Organizations
•   NCQA
•   Employers



      Blue Cross Blue Shield of South Carolina
               TRANSACTIONS
• Must include in standard transactions
• Must support dual coding standards
  – short and long term?
• Translators
• Publications



    Blue Cross Blue Shield of South Carolina
                       TRANSITION
                          Payer
•   Dual Standards
•   Archived Data
•   Distorted / Lost Statistics
•   Rating
•   Hard Copy
•   Reporting
•   Cross Year Functions
      Blue Cross Blue Shield of South Carolina
                       TRANSITION
                         Provider
•   Dual Standards
•   Archived Data
•   Distorted / Lost Statistics
•   Fees
•   Hard Copy
•   Reporting
•   Cross Year / Hospitalization Functions
      Blue Cross Blue Shield of South Carolina
                       TRANSITION
                          Other
•   NCQA
•   HEDIS
•   Employers / Reports
•   Business Partners / Subcontractors




      Blue Cross Blue Shield of South Carolina
                  OTHER
              CONSIDERATIONS
•   Fraud
•   Cash Flow
•   Patient Treatment
•   Cost / Benefit
•   Industry Wide Evaluation



      Blue Cross Blue Shield of South Carolina
                   CONCLUSIONS
•   VERY BIG CHANGE
•   HIGH IMPACT / RISK
•   HIGH COSTS
•   NOT FULLY DEFINED
•   APPROACH WITH CAUTION



     Blue Cross Blue Shield of South Carolina
                      QUESTIONS
• Nelly Leon-Chisen, RHIA - AHA
• Michael Beebe - AMA
• Jim Daley - BCBSSC




   Blue Cross Blue Shield of South Carolina
Blue Cross Blue Shield of South Carolina

				
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