ICD-10 Financial Risk Assessment
ICD-10 poses a unique set of challenges to payors including:-
- Financial impacts—DRG shifts will impact payment policies and reimbursement methodologies
- Medical Management—medical policy changes made to align with ICD-10 may impact business processes
- Contracting—contracts containing ICD-9 references may need to be updated to accommodate the greater granularity available in ICD-10
- Fraud and Abuse—the richer data set will impact the processes and algorithms used to detect fraud and abuse
But these challenges also bring opportunities. With ICD-10, payors can optimize payments, drive more focus into their care management and wellness programs, create more precise pricing structures, and incorporate more automation into reviews.
The question is, how can payors design a program that combats ICD-10’s impacts and takes advantage of opportunities?
The answer is RevCore.
The RevCore ICD-10 Financial Risk Assessment solution leverages Big Data technologies to help payors:- Identify high-impact providers and contracts
- Develop training priorities
- Identify documentation opportunities
- Create automated test scenarios
- Build test data
- And more…
ICD-10 Audit Services
Ensuring that you have a conversion timeline and plan in place that accounts for all of ICD-10’s interdependencies and impacts is one thing; ensuring that you are addressing risks and making the right business decisions is another.
For payors in the ICD-10 conversion process, we offer our a unique audit service that allows you to:
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- Simulate claims payments based on 12-24 month’s historical claims data to predict future payments, changes to medical policies and other claims adjudication rules
- Identify DRG, MDC, Service lines, Medical policies, Provider contracts and Codes causing maximum exposure and variation to claims payments
- Identify revenue and claims payment changes by Provider, TPA, specialties, contracts and by individual plans
- Provide inputs for rating and underwriting regarding plan structure considering future anticipated payments
- Identify future denial rates
- Audit impacts of future state claims on fraud and abuse
- Identify Clinical documentation requirements as a result of ICD-10
- Identify benchmarks tied to ICD-10 components including premiums, MLR (Medical Loss Ratio), utilization for high dollar claims.
- Identify and provide exposure areas around medical policies (coverage determinations, medical necessity requirements, clinical documentation) tied to claim adjudication process
- Identify exposure areas and top risks for case mix payments
- Evaluate credentialing process for anticipated high risk providers based on anticipated claim mix
ICD-10 Testing Services
ICD-10 has systemic, complex impacts for the entire healthcare industry. This level of complexity poses unique testing challenges for payors including how to:
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- Target testing efforts so that highest risk codes and operations are prioritized appropriately
- Ensure that business processes are accurately reflected in test scripts
- Coordinate testing efforts across organizations
- Ensure that test data is relevant and accurate
- Address limitations within testing environments
- Neutralize systems that are not ready for integration testing
- Ensure visibility into testing efforts, progress, and performance
To address payor ICD-10 testing challenges, Jvion developed icdcomplete—a software suite that supports all remediation and testing activities.
Through icdcomplete, we reduce risk and effort across all testing phases by:
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- Automating claims testing (can generate 8371 files for ICD-10 codes)
- Prioritizing testing efforts based on code and operational risks
- Generating test case scenarios based on impact and current usage of ICD-9 codes
- Providing IT and systems regression testing capabilities
- Providing a complete and integrated test case management solution
- Supporting level 1 and level 2 external testing
- Generating test data based on ICD-10 GEMs and custom crosswalks
- Neutralizing systems that are not ready for integration testing
- Providing dual coding assistance
ICD-10 Conversion Services
Leveraging the full capabilities of the icdcomplete software suite can reduce conversion budget and timeline by 30-50%. icdcomplete addresses the technical complexity of the ICD-10 code conversion so that you can focus on getting the most out of the new code set.
The Complete icdcomplete:
Having a software-enabled approach means that we can deliver solutions, recommendations, and services faster and with fewer resources. icdcomplete includes:
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- RevCore - ICD-10 financial risk assessment tool that provides encounter-level analytics enabled through the Bonobo Big Data Platform ™
- RevAssure - ICD-10 assessment and conversion support tool
- RevIT - ICD-10 system remediation solution that increases automation and enables better IT alignment to business needs
- RevWalk - ICD-10 crosswalk development solution
- RevTest - ICD-10 testing solution
- RevTrend - ICD-10 robust batch/real time, operational analytic solution
