Archive for the ‘Accountable Care’ Category

ICD-10 Impacts Case Management and Case Management Reporting

Thursday, January 30th, 2014

ICD-10 assessment and implementation planning activities create many possible areas to focus on so it is important to prioritize those that are most critical to patient care and reimbursement.

When thinking about ICD-10 program governance, one of the key areas for both traditional Fee for Service (FFS) medicine and the transition to episodic (short-term) and longitudinal data for comparative effectiveness medicine in the Affordable Care Act is the Case Management process and supporting software and reports.  The member or patient, provider, case management RN, and dedicated Medical Director,  and Case Reviewers all collaborate in this process.   Therefore, the transition to ICD-10 creates just one more reason to take a closer look at Case Management and Case Management reports.

In our over 30 years’ experience in software development, IT systems and healthcare IT, we have found that reporting is one of the most overlooked areas by developers of solutions like these, but one of the most critical for users of these systems.

Does your organization depend on reports for Case Management?  If so any ICD-9 related information in those reports will need to be updated for ICD-10 if they contain procedure codes or diagnosis codes in ICD-9 today.

Some of the impacted systems, and processes to consider include:

  • Referrals (Utilization Management, Condition Management, Self-referrals, Client requests, Provider requests, etc.)
  • Targeted high volume, high cost, high risk diseases
  • Analytics, including predictive modeling, ICD-10 financial risk analytics, and population health management analytics
  • Clinical decision support
  • Plan compliance reporting
  • Inpatient reporting (bed days, denials, readmissions)
  • Shared savings, bundle payments, capitation, PMPM
  • Cost reporting (fee for service, case based, benchmarked, per diem)
  • Medicare Advantage specific measures (HEDIS, 5-Star Ratings)
  • Home health care
  • Medical necessity
  • DME
  • and more

Related Posts and Resources

  1. Case Management Guide for Providers from CMS
  2. Case Management, RAC Audits, Revenue Cycle Management and ICD-10
  3. ICD-10 Consulting
  4. ICD-10 Financial Risk Management
  5. ICD-10 Assessment and Data Quality
  6. ICD-10 Remediation
  7. ICD-10 and Interoperability
  8. ICD-10 Best Practices



Get Ready for Obamacare

Monday, September 23rd, 2013

On October 1, 2013 Health Insurance Exchanges (aka Insurance Marketplaces or HIX) will start operating.  Here is an overview of some of the things consumer can expect.  Click the “play” icon to view a presentation from Kaiser Family Foundation.  “Obamacare” is short for the Patient Protection and Affordable Care Act.

Interestingly, Obamacare including HIX and Accountable Care Organization (ACO), will be impacted by a new data standard called ICD-10.  Many don’t see the second order impact of multiple regulations.  The data that wil be used in future coverage determinations, health of patients, and the financial exchange will be based on ICD-10 which was mandated before Obamacare.  The  healthcare economics related to disruptive standards such as ICD-10,, Meaningful Use of Electronic Health Records, and CORE Operating Rules, and other components come together in a mosaic of sorts that create unprecedented risk and unprecedented opportunities in health care.

We have worked with leading employers, law firms, healthcare IT firms, health plans, and hospital systems on all aspects of the law.

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