When a claim is submitted to EmblemHealth, the proper determination of benefits and payment is based on highly complex business rules embedded in the claims adjudication systems (QCare, HCS, MCS). The rules are based on multiple data from the claim forms (member, plan, provider, affiliation, diagnosis, procedure, preauthorization, etc.), and many rules include ICD-9 codes. These rules all need to be updated to accommodate the new ICD-10 codes. Over 16,000 places where ICD-9 diagnosis codes are present within our various claims systems are already identified, but the complete inventory is not yet final.
Why Is Updating Business Rules So Challenging?
The mapping of ICD-9 codes to ICD-10 codes is challenging because there are many more ICD-10 codes (142,000 compared to 18,000). Even though the Center for Medicare & Medicaid Services (CMS) has provided a mapping model as a recommendation, EmblemHealth must build maps based on its specific business needs. The mapping exercise must meet three distinct objectives: * Clinical equivalency: ICD-10 codes are consistent with ICD-9 codes from a clinical standpoint. * Operational neutrality: Claims processing performance with ICD-10 is as efficient as with ICD-9. * Financial neutrality: The transition to ICD-10 does not affect benefits and payments.
How Are We Organized to Manage the Effort?
A dedicated team: Business rules constantly evolve based on new business needs and are regularly updated by the Business and Technical Services department (BTS). Given the magnitude of the changes, the remediation efforts for ICD-10 are managed by a specific team — the Business Rules Remediation workstream — within the ICD-10 Remediation Program. Currently composed of 15 members and led by BTS Senior Director Russell Ritzer, EPMO Program Manager Mike Tanner and EPMO Project Manager Medha Gokhale, the team will expand to over 60 people. The team collaborates with other workstreams, including the Benefits and Claims and the Medical Management workstreams, to update all business rules.
A proven technology: EmblemHealth is currently implementing Edifecs ICD-10 Solution, a leading mapping tool that automatically identifies relationships between ICD-9 and ICD-10 codes based on claims history and existing business rules. The software facilitates the detection and