The ICD-10 migration has revealed that the change in diagnosis-related grouping (DRG) codes will have severe financial and operational impacts on Healthcare

providers. A provider’s success will be determined by a streamlined ICD-10 migration and aversion of any regulatory risks. One of the greatest financial risks lies with claim reimbursements, where there will be a variation in payer settlements for a medical condition treated and coded in ICD-9, compared to the same in ICD-10, leading to discrepancies in settlements.

• Medicalcoding– Identifying appropriate ICD-10 codes, based on rules and preferences defined in the provider’s guidelines for medical coders

• Medicalbilling –Improper rule definitions will impact reimbursements, rendering business edits remediation critical

• Denialmanagement – Increased claim processing time due to a large volume of denials, appeals and pending claims

• Contractmanagement – Payer contracts may have to be renegotiated to mitigate the risk of under/over reimbursement

• Adjustmentstoreimbursements – Reimbursement amounts are based on the severity of diagnosis, and analysis is required to understand changes in Health Plan coverage and cash flow which may require future adjustments

• Payforperformance–Incentives from payers and governing bodies for various treatments and linked reimbursement schemes will be affected

Achieving Reimbursement Neutrality and Encouraging Rapid Claim Settlements in ICD-10

This assessment would include the following features:

RemittanceAdvice(RA)Analysis–Remittance-oriented analytics assist in evaluating claim decision information, and review adjustments for improving and optimizing the provider’s claim submission process

MedicarePaymentAnalysis – Investigating exceptional medical cases, where the expenses of services vary from standard rates, may prove useful in reviewing contracts

Hospital-acquiredconditions(HAC)basedclaims - Claims scrutiny, based on HAC indicators, highlight reimbursement losses and assist in verifying operational efficiency measures

FinancialNeutralityreports – A set of financial analysis reports, referenced to DRG amounts, billed amounts, reimbursed amounts and net reimbursement amounts, serves as a platform to foresee reimbursement gaps

The discrepancies in these settlements can lead to inaccurate underpayments or overpaid reimbursements from payers for services rendered by providers. To avoid disputes, discrepancies and patient discomfort, providers should select an IT partner who can assist them in overcoming these challenges.

Syntel’s Solution Syntel’s nSure10SMReimbursementRiskAnalysisServices enable providers to assess the effect of ICD-10 migration on future revenues, allowing them to mitigate risks and minimize losses. Our in-built tools ensure a smooth operational workflow and allow you the dual advantage of functional and financial stability throughout the ICD-10 migration process.

Our team of domain experts and technical analysts use a unique six-phase reimbursement neutrality methodology to assess a provider’s reimbursement risk:

CHALLENGES FACED IN CLAIMS REIMBURSEMENT

Data Extraction

Identify data sources for RN Analysis

Data Formatting

Syntel’s Format Converter:

•Data transformation•Data uploading

Data Sampling

iTAP framework:•Data selection based on business criteria

Data Analysis

Syntel’s Reporting :•Analytics demonstrat-

ing variance

Data Prioritization

Data :•Prioritize simulated

data analysis based on business parameters

Data Simulation

Syntel’s Comparator & iTAP:

•ICD-10 sample data generation

•Determine cost weight for ICD-19 and ICD-10

Billing Data

Analytical Reports

Syntel’s Reimbursement Neutrality Methodology

Achieving Reimbursement Neutrality and Encouraging Rapid Claim Settlements in ICD-10

© 2013, SYNTEL INC. 022013

For more information, visit Syntel online at www.syntelinc.com or call us at US/ +1 (248) 619-3503 UK/ +44 (0) 207-636-3587

Salient Features of the nSure10SM Solution

• A robust ICD-10financialriskanalysisandmodelingframework, with a defined approach and accelerators

• Automated sampling and prioritization of test data, through set parameters and in-built scientific algorithms using Syntel’s iTAPTestDataManagementtool

• Embedded DRGGrouper for variance calculation• Customizable approach to suit specific organizational frameworks• Simulator testing platform for test execution, through Syntel’s NeutralitySimulationLab• Volume data generation through test data management, integrated with crosswalk for automatic

ICD-9 to ICD-10 billing data conversion

• A leading global IT and KPO service provider

• Established in 1980 (NASDAQ: SYNT)

• More than 24 offices in North America, Europe and Asia

• Flexible onsite-offshore global delivery model

• Dedicated Centers of Excellence (CoEs) to help clients with expert advice and project guidance

• World-class services and tools to enable, enhance and integrate the payer-provider relationship in the Healthcare industry

This analytical approach will benefit Providers by enabling:

• Support for intelligent decision-making through comprehensive reimbursement variance reports and dashboards

• Risk measurement through granular reports with causal analysis to depict payment variations

• The ability to leverage historical billed data and conduct an in-depth analysis

• Simulation of ICD-10 billing data in a controlled environment, based on ICD-9 data

• Processing of ICD-9 and ICD-10 billed data, to generate gross reimbursements as per DRG assignments

• Comparison of two references for verifying the variance in the reimbursement

• In-house medical records to conduct the simulation and complete the risk analysis

WHY SYNTEL?

BUSINESS BENEFITS

Screenshot of the Neutrality Testing Reports