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
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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
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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