Wednesday, July 27, 2011

Achieving Neutrality in your ICD-10 Solution Design

People who’ve been involved with ICD-10 assessment and remediation projects gain a quick understanding of the depth and breadth of the challenge they are facing.   While the transition to ICD-10 offers many strategic opportunities for payers and providers, the immediate challenge is to achieve compliance while maintaining the status quo of existing business processes and financials through the Oct 2013 transition date.

This post identifies some of the primary areas of focus for achieving neutrality in your ICD-10 solution design.  Also included are key challenges to overcome in order to achieve neutrality in your ICD-10 solution design.

Focus Areas

1.       Financial Neutrality

Financial Neutrality means maintaining reasonably equivalent financial outcomes with your trading partners both before and after the conversion to ICD-10 is completed. Member benefits and provider contracting/pricing are two key business areas to neutralize.

2.       Process Stabilization

Process Stabilization means that your internal and external business processes can be carried out on a consistent basis before and after the transition date.  Key areas to ensure stabilization include Case Management, Utilization Management, Disease Management and Reporting.


1.       Defining a Remediation Solution for existing business processes and software components that maintain existing operational performance and financial metrics.

2.       Ensuring that business processes, software components and trading partner interactions are predictable and consistent.

3.       Defining a framework to ensure integrity of the solution design BEFORE and AFTER the transition date.

4.       Identifying and creating contingency plans and the gates and levers that trigger these plans.

In future posts, I’ll share additional knowledge, perspective and insight into the topic of solution design neutrality with the hope that others share their ideas, concerns and perceptions. Like a good relationship, a little give and take goes a long way toward pleasing everyone involved.

Thursday, July 21, 2011

ICD-10 Awareness Education & Training for Healthcare Payers

The hubbub around ICD-10 seems to be focused on the provider-side of the provider-payer equation; specifically in regards to how ICD-10 impacts clinical documentation, claim coding and reimbursement.  A whole host of education, training and awareness-building products and services are being offered (and pushed) at providers by a wide range of companies including traditional healthcare IT vendors, mainstream education/training firms, various associations like AAPC and AHIMA and even some old-school accounting firms. 

But there appears to be a dearth of similar offerings targeted at healthcare payer staff charged with assessing and remediating their business processes and software systems.

What would an ICD-10 Awareness Program for hHalthcare Payers Include?

1.     The usual overview of ICD-10 code structure and differences from ICD-9.
2.     An overview of other codes impacted by ICD-10 including DRG’s, MDC’s, and HCC’s.
3.     Enumeration and high-level review of payer business processes and applications impacted by ICD-10 and related codes.
4.     An overview of ICD-10’s potential reimbursement impact including DRG shifts and changes in case mix index.
5.     Review requirements for basic ICD-10 compliance and identify opportunities for strategic differentiation.
6.     How changes to External Codes (E Codes) impact 3rd party liability/subrogation.
7.     Review how discontinuation of explicit Status Codes (V-Codes) will impact certain processes and applications.
8.     Identify and discuss challenges and options related to ICD-10 impact to actuarial, underwriting and other financial models.
9.     Overview of mapping, crosswalk and general equivalency data sets and tools including a survey of currently available and evolving products and services.
10.   Overview of methodologies, approaches and tools that can be used to assess and remediate business processes and applications.
11.   Presentation and review of opportunities, issues and risks associated with ICD-10’s impact to longitudinal data analysis.
12.   Identification and review of commonly expected remediation patterns.
13.   Enumeration and review of automated processes and software tools that can be used to facilitate the assessment and remediation process.

What would an ICD-10 Awareness Program for Healthcare Payers NOT Include?

1.   Detailed overview of ICD-10 coding.
2.   Detailed, payer-specific consultative and advisory services.
3.   A bunch of high-priced consultants on-site for days on end.

Who would an ICD-10 Awareness Program Benefit? 

1.    Departmental managers and supervisors who need to quickly get up to speed on ICD-10.
2.    Business analysts and information architects charged with ICD-10 assessment and solution design.
3.    Software developers who’ll be performing remediation.
4.    Quality assurance and technical writers charged with validating and implementing remediated systems.

I think a payer-focused ICD-10 Awareness program would help leverage existing resources, lessen dependency on expensive consulting resources who often learn on the job at the clients expense and lead to better overall outcomes.  Who’s out there that can provide this needed service?

Saturday, July 16, 2011

ICD-10 Considerations Payers & Providers Oughta Think About

Here are some specific areas payers and providers may want to consider:
  1. Application Inventory & Identification of Software Changes (Data, Logic & UI)
  2. Identifying Impacts to Core System Setup, Administration & Reporting
  3. Utilizing Methodologies, Best Practices, Checklists, Tools, and Templates
  4. Identifying, Communicating, Managing & Validating Impact of External Entities
  5. Remediation: Design Specs, Construction, Validation & Implementation
  6. Leveraging ICD-10 Investment Beyond October 2013
  7. What’s the Difference Between Mapping, Crosswalks & General Equivalencies?
  8. Marrying Business & Conversion Strategies – Pre & Post October 2013
  9. Financial Neutrality: Medical Loss Ratio, Predictability & Profitability
  10. Impacts to Actuarial, Underwriting, Contracting and Reimbursement
  11. ICD-10's Impact to Medical Policy, Care Management & Disease Management Programs
  12. Fraud & Abuse: Challenges and Opportunities from Increased ICD-10 Granularity
  13. Understanding Impacts to DRG’s, HCC’s, Case Rates, APG’s, Carve Outs & Other Groupings
  14. How Might/Could/Will ICD-10 Impact P4P, ACO’s, Meaningful Use & Other Reforms?
  15. Bridging the Digital Divide & Data Fog Due to the ICD-9 & ICD-10 Transition Period
  16. Considerations and Impacts Related to Dual Processing of I-9’s and I-10’s
  17. Contingency Planning for Nov 2013 – Preparing to Avoid the Hangover Effect
I'm ready to help those who ask me to expound on any of the above.


ICD-10 Assessment & Remediation - How Can I Help You?

Where are you with your ICD-10 Assessment & Remediation Project?

I'm starting this blog to share my extensive experience providing consulting services to health care payers and providers.

You can learn a bit more about me by checking out my profile on LinkedIn ->
I also actively tweet about ICD-10 and related health care information topics on Twitter ->!/shimcode

In order to provide the greatest value and to mix things up on a regular basis, I will respond to requests for information on ICD-10 and other health care IT topics.  For instance, in regards to ICD-10,

  • What is your current biggest challenge?
  • What is your greatest risk?
  • What are the key questions you as a provider have for a payer?  and vice-versa?
  • What specific areas of the assessment or remediation process would you like more information about?
Respond here or send me an email at

I will do my best to respond to all requests.

We'll see how this goes!

ShimCode - aka. Steve Sisko