As healthcare organizations pursue improvements in productivity and clinical outcomes, they are also increasingly turning to business intelligence (BI) systems and staff to provide the data and tools needed to achieve and sustain such gains. The problem is, many organizations’ BI teams – tasked with a myriad of urgent and competing internal demands – often lack the experience, bandwidth and/or big-picture strategic and analytical skills needed to adequately respond to their organizations’ heightened needs.
That was the dilemma faced by a health maintenance organization (HMO) that had doubled its membership and found its BI team ill-equipped to respond to its growing technology needs. The HMO’s experience in recognizing and addressing its BI issues provides a template that other organizations can follow when confronted with similarly pressing BI demands.
The Four R’s of Quality BI Performance
The greatest positive emerging from the HMO’s BI issues was a wholesale reassessment of its BI team’s role, responsibilities, responsiveness and resources. You can call these the four fundamental R’s of well-functioning BI team performance:
Role – Rather than being focused on “doing,” a well-functioning BI team should also consider itself to be a vital strategic partner in the health care organization’s business. Attitudinally and functionally, a BI team needs to operate as a key part of the organization’s business team.
The HMO installed a new BI leader who immediately focused on mentoring and developing existing staff, overseeing and assisting with business analysis and reporting functions and defining a strategic path for the team to meet the HMO’s organizational strategy. This leadership change quickly stabilized the BI team’s performance and enhanced its ability to more effectively respond to internal requests. Your BI team’s leadership should be capable of achieving similar performance.
Responsibilities – Instead of simply being “order-takers” and “project fulfillers,” well-functioning BI team members should be high-quality strategic and process partners with internal clients. Creating and having in place service level agreements (SLAs) between a BI team and its business clients is crucial for establishing expectations for timing, deliverables and process improvement measurement.
For the HMO, the BI team’s new SLAs defined responsibilities for each business team member involved in project requests, performance objectives, documentation and sign-off requirements at milestones. The SLAs also provided project quality measurement standards, project success definitions and internal satisfaction reporting. Do your SLAs provide similar levels of accountability and clarity?
Responsiveness – Delays in responsiveness to client requests are not only inappropriate, they detract from a BI team’s professionalism. Established operational guidelines should delineate proper responsiveness for members of your BI team.
Though ICD-10 is upon us and there is little, if anything, that can be done at this point other than wringing your hands in disbelief or praying for peace with the patience of a saint (depending on your religious worldview and personality), we wait for the storm to hit, then pass and roll on a bit for a time. And it will pass. The storm will dissipate.
For some reason, when I think of the current state of ICD-10 and its impact to healthcare I’m reminded of a hurricane. The analogy of a hurricane seems like an apt example of the phase healthcare currently is in in regard to ICD-10.
The road here has been long – there has been much fear and anticipation of the coming storm. Surges of energy, wind and waves have met us and battled at the banks of the beach. The wind and thunder has been loud, the elements seem to have shaken the very foundation of our lives and our “homes.” Pain, fear, struggle and stress have been the order of the day. But at last we’re here. The storm is upon us, in fact it is half over, and we stand in its eye, one of the most beautiful and peaceful times one can ever experience.
Peace, calm expectation and a subtle excitement of the storm’s beauty are in the eye, as is anxiety of the anticipation of what’s to come — the second half of the storm. Having personally stood in the eye of one of the largest hurricanes on US record, and having survived one of the most terrifying storms of my life, I can tell you that the eye of the storm is a brilliant, calm and peaceful place in what is actually an extremely deadly and dangerous place to be.
However, when the eye passes, the storm rages again, even more fierce than the penetrating force of the first half of the storm. Again, there’s more fear; more stress; more panic. Finally, the storm passes, slowly and subtly. The wind disappears, the sun breaks free and among the chaos, birds sing with striking clarify and beauty. It’s as if their songs are the only remaining sound because the storm has sucked all else away. Their song is an encouragement as you assess your losses and determine the first steps required to put your life back together.
Certainly, ICD-10 is not deadly, nor is it as dramatic as surviving a killer storm, but the process has been stressful, and painful and chaotic for millions. We’re in the eye, half way between beginning and end. Much has happened, but there is still a great deal more to come. I image that’s how many of you are feeling today; trying to ride out the storm — in peace, in fear or maybe a combination of the two. So, on this occasion, as we wait, I thought I’d provide a few final thoughts about ICD-10 from those working alongside you, in the trenches, who are also weathering the storm. Hopefully these insights provide you some peace, and help you get through this stressful time.
With the transition to ICD-10, we expect three types of industry disruption occurring at different times. First, starting in the first few days after the Oct. 1, 2015 cutover, when providers start transmitting claims containing ICD-10 codes (between 10/3 and 10/10), we predict that providers that chose to ignore the ICD-10 mandate will receive a monumental wake-up call when clearinghouses and payers immediately reject their ICD-9 coded claims as non-clean HIPAA transactions. We believe that most of the nonconformists will be smaller, rural professional providers and small practices. They will scramble to get ready in short order if they wish to be paid for their services.
Second, by mid- to late-October, providers will start receiving payments based on claims submitted using ICD-10 codes. Most professional claims are reimbursed based on the CPT/HCPCS codes and therefore are not susceptible to payment shifts. Institutional claims are paid via a wide range of reimbursement mechanisms, mainly due to combinations of both ICD-10 diagnosis as well as procedure codes. ICD-10 testing between providers and payers illustrates that four out of five payment disputes are because of poor coding accuracy from the provider. We see an increase in phone calls to payers and an elongated revenue cycle collection timeframe.
Third, throughout 2016, we see overall data quality issues emerging as the industry stabilizes and acclimates to the new code set. Although CMS relaxed coding accuracy requirements for Medicare fee for service claims, commercial payers have not followed suit. Be prepared for an increase in chart reviews and ongoing adjustments to previously paid claims.
Coastal Orthopedics has been serving the coastal South Carolina region for more than 30 years, and has helped countless members of our community regain and maintain a full quality of life. In those years of serving our community, ICD-10 has without a doubt been one of the biggest challenges that our practice has faced to date. With major overhauls to our practice workflow and ultimately our ability to provide the best care to our patients on the horizon, we set out early to meet the demands of the ICD-10 transition proactively.
The success of our transition to ICD-10 has been two-fold. One: our software partners (SRS Soft EHR and Allscripts Practice Management) have continued to deliver exceptional tools that have allowed our practice to leverage the power of healthcare information technology to expand our ability to provide exceptional care exponentially. Two: The dedicated staff and physicians of our practice, who truly love getting to be a part of helping our patients live their best life, have invested countless hours of preparation into being sure that our patients continue to receive only the best care. After months of updating our office systems/processes, working with care partners across the community, working with our software partners to fine tune our systems, and working with insurance companies to ensure that our patients get the most of their benefits, we’re ready to take ICD-10 head-on.
October 1st will be just another day of providing exceptional orthopedic care to our community for Coastal Orthopedics.
The day before, the day of and the day after ICD-10 goes live, it will be too late. But, as we get closer to ICD-10 go live, there are some final preparations that you can do before it does, and some remediation that can be done post go live. Physician practices and hospitals can focus on the procedures and visit types that drive their practices. We call this focus, the Codes that Matter. A very small percentage of procedures and visit types drive 95 percent of revenue so focus on those key areas to protect your revenue.
In addition, the physicians and hospitals need to take a snap shot of financial and revenue cycle performance prior to going live. This is especially critical at this point. The hospitals and physician practices have to know where they are today so they can effectively evaluate their financial and revenue cycle performance post go live. Financial “fire drills” need to be conducted to practice and prepare for revenue cycle impacts. How to prevent 10 percent to 15 percent revenue hits? If we see those issues arising, how do we quickly address and how do we rapidly deploy teams to close the issues. Waiting until the day before, similar to cramming for the test will not work well for the October go-live. There are a couple of things listed above that can still make a difference so the time is now before the die is cast.