Healthcare Regulatory Compliance Services
— Adopting new regulatory standards in the US Healthcare Industry
The purpose of this paper is to provide a clear understanding of HIPAA and ICD migration, analyze the benefits beyond ICD remediation by providing regulation insights, and discuss the impact of the new regulations on systems, processes, payers, providers, pharmacies, laboratories, and Intermediaries, healthcare organizations, and the industry in general. In addition, it provides insight on the implementation in the healthcare ecosystem.
Industry Challenges:
The two major US healthcare regulatory compliance mandates are, HIPAA migration from 4010 to 5010 electronic transaction set and conversion of ICD-9 code set to ICD-10 code set. Implementation of these mandates will impact every core process, system and interface across the industry and will require a major overhaul in healthcare organizations.
The government has stated specific time lines within which migration and replacements have to be completed.
- HIPAA 5010 Compliance is to be completed by January 1, 2012. All electronic claims provided after this date must use Version 5010 and Version 4010 claims will no longer be accepted.
- ICD-10 Compliance is to be completed by October 1, 2013. Claims for services provided on or after this date must use ICD-10 codes for medical diagnosis and inpatient procedures.
Migration of ICD 9 to ICD 10 and meeting the compliance deadline of October 2013 will require a significant amount of awareness, planning and preparedness on the part of payers as well as healthcare professionals. Network management, claims re-pricing, and Provider Contracting constitute the biggest concerns for ICD-10 and HIPAA transition. Integration between web-based technology and administrative services to improve consumer experience is another major challenge for ICD-10 and HIPAA transition. The conversion will also largely impact rating, underwriting, and actuarial policies and guidelines in the Healthcare industry.
In order to meet the compliance deadline and increase the success rate of ICD compliance, payers need to work out a strategic approach to manage change and maximize benefits out of investments. The immediate need is to start the effort with an overall governance structure and manage the transition and mitigate the risks.
HIPAA 5010 Migration
The adoption of HIPAA 5010 is imperative to enable ICD-10 implementation. It involves adopting new guidelines for claims, eligibility inquiries, referral authorizations, remittance advices and other transactions. The migration process adopts an updated version of the National Council for Prescription Drug Programs (NCPDP) standard and a standard for Medicaid pharmacy subrogation transactions.
These new HIPAA regulations have various organizational and technical implications in the industry. Healthcare providers, pharmacy benefit managers, doctors and other enterprises operating in the industry are implementing new standards in order to facilitate the interoperability of stakeholder systems and drive efficiencies.
In order to implement HIPAA migration, there are some basic changes that organizations need to make.
Typical Changes for HIPAA Migration—
- Front Matter Changes – the purpose and business rules related to the transaction under consideration needs to be identified.
- Technical Improvements – facilitation of effective accommodation of the transaction data collected and transmitted, as well as ensuring that the transmitted data is more comprehensible.
- Structural changes – incorporating modifications to the physical data element components of the transactions.
ICD-10 Migration
The US Department of Health and Human Services (HHS) has proposed a regulation that will replace the ICD-9-Clinical Modification code sets (used to report healthcare diagnoses and procedures), with the new advanced and expanded ICD-10 code sets. The challenge that is being currently being addressed is the transition to new ICD-10 coding. It involves a major overhaul of the current coding systems in all Healthcare organizations. Considering the confidentiality of medical records, automation and up gradation of IT systems require immediate attention.
Migration of migrate from ICD-9 to ICD-10 code sets, involves a major system overhaul, leading to the following changes:
- Increased code set from 18000 to ~140000 and
- Structural changes for the codes to Alphanumeric from Numeric format
- Code size increased from 5 to 7 character length and leading to higher data volume
Typical Changes for ICD-10 Migration
- Increased code sets – accommodation of increased code sets from 18000 to ~140000.
- Increased code sizes – increasing the character length from 5 characters to 7 characters to enable higher volumes of data.
- Structural changes – incorporating change in codes from numeric to alphanumeric formats
Business Benefits of migration to ICD 10 and HIPAA 5010
The benefits of migrating to advanced regulatory standards of ICD-10 and HIPAA 5010 are:-
- Facilitating interoperability of stakeholder systems and drives efficiencies.
- Enhancing usability and effectiveness of transactions such as claims, eligibility inquiries, referral authorizations, remittance advices and other transactions.
- Enabling integration of codes of different versions across systems in the industry.
- Providing standardization of interoperability guides between systems across the industry.
- Increasing protection of personal medical information (PMI) through limiting ways in which information is shared.
- Assisting healthcare consumers in purchasing appropriate health insurance coverage.
- Enabling easier accessibility of individual records by patients.
GSS' Solution for Code Conversion: GSS Infotech Experience and Expertise
GSS Infotech provides software and services that can be customized and implemented based on your organizational needs for compliance mandates. The Medicode, an e-learning tool by our expert services, helps not only cut down on the time and human resources required for transition to ICD-10, but also ensures accuracy and consistency in code count and conversion. The tool is a powerful web-based solution, designed to guide your experts through the process of translating codes throughout your business systems and processes to help you maintain your financial health.