WALTHAM, MASS.--Harvard Pilgrim Health Care completed its ICD-10 assessment in 2011 and began detailed planning in 2012, said Rita Hunt, the organization’s ICD-10 program manager, speaking at the Massachusetts Health Data Consortium’s March 10 conference on ICD-10 planning.
Harvard Pilgrim completed core system remediation by the end of September 2013. “We had to defer certain items,” said Hunt. “We had to make decisions and we decided to focus on our core systems.”
The assessment included five phases, said Alan Bengzon, advisory manager for PricewaterhouseCoopers, who is working with Harvard Pilgrim. The team conducted interviews with core business operations staff and validated the findings through a series of cross-functional interviews. They identified just over 150 unique requirements that would need remediation for ICD-10, he said. They also identified several others that represented future opportunities—“we don’t need to do them right now but we should keep them on our radar to see whether ICD-10 would introduce any performance improvement opportunities.”
There is a misconception that ICD-10 is an IT issue, Bengzon said. “That is certainly not the case. Our assessment revealed that a significant contribution from the business side is required.”
The team created a custom, all possibilities diagnosis map using GEMs as a starting point that addresses the known deficiencies inherent in GEMs. “Diagnosis codes were drivers for much of the system logic used at Harvard Pilgrim which is why it is our primary focus.” Procedure codes would be managed on a separate project.
A cross-functional team reviewed GEMS, developed recommendations for mapping changes, additions and deletions, and came up with a final map. They also reviewed existing GEMs for codes associated with high-dollar, high-volume claims and did additional mapping possibilities which Harvard Pilgrim used as guidance and a starting point for remediation.
They identified business areas using ICD-9 logic and used the map to identify all ICD-10 coding options, said Hunt.
Vendors were categorized as low, medium and high risk, said Bengzon. Harvard Pilgrim uses a lot of service vendors on an ad hoc basis so if one is not ready, it won’t be difficult to choose another one. Those categorized as high risk are companies the plan needs to stay in constant communication with to ensure they’re on target with ICD-10-capable solutions.
For actual testing, Hunt said Harvard Pilgrim does not want a “big bang approach.” They will support the need for dual processing while minimizing the organization’s risk. “We have a goal of operational stability. The last thing we wanted was identification of showstoppers late in the process.”
Testing includes four major activities: unit (developer) testing, acceptance (business), internal enterprise and all three segments for external partner testing. “We’re at that stage now,” she said. Harvard Pilgrim is one of the participants in the collaborative testing program.
For external testing, Harvard Pilgrim will conduct New England Healthcare Exchange Network beta testing; referral/authorization testing; claim submission self-testing; and claims to payment. “We’ve identified a limited set of providers. Because it’s very expensive to test with all external partners, we’re trying to find those with breadth,” said Hunt.
Harvard Pilgrim’s testing strategy includes engagement, test strategy planning, test preparation, test execution and test results discussion.
Once the ICD-10 transition occurs, the organization will focus on post-implementation compliance. “We need to transition this to business operations,” Hunt said. “We’ve been having business people sign off on the transition so it’s not in the program anymore and ‘now it belongs to you.’” That allows for a more collaborative process, she added.
To communicate with everyone within the organization, Harvard Pilgrim has been using a website, FAQs and a link people can post questions.
Among the challenges and lessons learned, Hunt said, are to gain ongoing support from leadership early on, engage business stakeholders early and involve them in planning and implementation, manage key dependencies to decrease their impact on the timeline and understand how data should drive implementation strategies. She also said organizations should tightly manage their change control process. “We didn’t make it easy for people to change dates. That was not popular, but it worked.”
When the Centers for Medicare & Medicaid Services announced a delay, Hunt said Harvard Pilgrim did not stop its ICD-10 effort. “Maintain momentum from the initial assessment until the go-live date,” she recommended.
Hunt said engaging with other healthcare organizations will help in sharing leading practices. “Lots of providers are willing to work with us.”
At this point, Harvard Pilgrim is concerned most about whether external partners will complete their readiness on time and how they will minimize risk for unexpected surprises. “It’s dynamic. How we deal with change and maintain focus has been really helpful.”
Going forward, Hunt said Harvard Pilgrim plans to ramp up external partner testing, continue to tightly manage remediation, monitor vendor remediation, assess and analyze risks and refine its approach for post-compliance risk monitoring.