Case Study

How a pharmacy healthcare service provider ensured compliance with ICD-10

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Client:
An integrated pharmacy health care services provider in the United States

Industry:
Healthcare

Business need addressed:
Migration to ICD-10 is critical for the healthcare industry to ensure compliance and to prevent revenue leakage and protect profitability. However, ensuring seamless operation across payer and providers’ systems and processes can be complex and costly.

Genpact solution:
An end-to-end testing solution supported by Genpact’s ICDnXT migration engine enabled the complete automation of the analysis, test data creation, conversion, comparison, and reporting activities for ICD-10 migration.

Business impact:

  • Regulatory compliance
  • Adaptation and flexibility
  • Standardization and simplification

The Healthcare industry faces a major challenge to comply with the updated standards, from ICD-9 to ICD-10:

  • The classification includes more than 16,000 codes for diseases and their signs and symptoms.
  • Correct migration is crucial to profitability because classification affects how payers reimburse providers. From a revenue perspective, correct migration reduces incidents of disputed payments payers owe, when the provider must be paid by the payer for services rendered.
From a revenue perspective, correct migration reduces incidents of disputed payments payers owe, when the provider must be paid by the payer for services rendered.
  • Doing this correctly is crucial because there is a big financial risk if the provider does not complete the standards or coding migration properly.
  • As part of the migration, organizations must determine which codes to test in order to optimize the cost involved in testing codes and ensuring timely compliance.
  • To add more complexity, lack of coordination in ICD-10 migration initiatives across payers and providers restricts the ability to ensure that the optimal volume/scenarios are identified and tested end-to-end.

Genpact solution

  • An end-to-end process review (from provider to payer and then back to the provider) was conducted to lay the foundation for understanding the depth and breadth of the impacts and set the strategic direction and guiding principles for the overall initiative.
  • A 360-degree test process pulled ICD-9 claims data to determine what codes to actually test. This was the key to mitigating ICD-10 implementation and production cost risks

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  • Accelerators like the ICDnXT migration engine were deployed to automate the analysis, test data creation, conversion, comparison, and reporting activities while mitigating the risks posed by the complex coding changes required to complete the transition to ICD-10.
  • The ICDnXT migration engine empowered ICD-10 decision makers to identify their most frequently used diagnosis and procedure codes as well as high-dollar, high-volume, high-risk, special, and critical accounts claims.

The end-to-end testing methodology anticipated the effects of the new processes on the provider and its payers, and confirmed both groups understood the impacts of the changes.

Solution highlights

  • Providers can report new data in ICD-10 and historical data in ICD-9
  • Enabled dual coding support, with minimal impact on legacy applications
  • Accelerated time to compliance, while causing minimal impact to current operations
  • Prevents payment delays and reduces cost by eliminating need to remediate legacy applications, while mitigating the enterprise risk associated with such end-to- end changes

Business impact

  • Today, the correct ICD-10 code appears in each patient’s electronic medical record, and correct payment requests are sent to the payers for reimbursement.
  • Providers can significantly reduce the cost and time involved in testing the migration while still achieving full compliance with ICD-10, minimizing enterprise risk and revenue leakage.

For more information, contact, healthcare.solutions@genpact.com and visit, genpact.com/what-we-do/industries/healthcare-payer

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