powerpoint presentation update... · 2014-02-05 · title: powerpoint presentation author: omar...

e-Prescription Initiativefor Dubai Insured Population

May 5, 2013

Update

and

Components

Committees : DMCC, EDSC

In development, release planned in 2013

Developed but not active yet as of end of Q1.2013

Regular Training Sessions & Support Call CenterSupport Services

In Numbers (claims till April 30, 2013)

55Facility Registered Payer/TPA

Registered

1,561Person Trained

2500+

Started eClaims in June 1, 2012 – Only

Enaya

ALL Providers and ALL Payers to

eClaims starting January 1, 2013

as of May 1, 2013

Number of Monthly Claims Submitted on eClaimLink in 2013

478 K Claims190 M in Gross165 M in Net

15 M in P.S.

In Numbers (claims till April 30, 2013)

Activity

Claimed

3.8million

16,995

Diagnosis

Code Used

Unique Diagnosis

Codes Used

Physician Provided

Services

6,647

50Unique Activity

Conducted

Payer/TPA

Received Claims

2.1million

9,571

Activity Types Net Value Distribution

Net Distribution by

Activity Type

CPT47%

HCPCS 4%

Drug 23%

Dental 3%

Services 23%

e-Prescription Initiativefor Dubai Insured Population

e-Prescription – Process in Dubai

30 seconds average

30 seconds average

Outpatient Setting

PhysicianShall only use eRx for the insured patients

• Generate & Post eRx on eRx Hub (using eRx Physician solution or their own solution)

• Communicate to patient on payer & DHA messages• Provide patient with the eRx number

PharmacyShall only use eRx for the insured patients

• Download eRx from eRx Hub (using eRx Pharmacy solution or their own solution)

• Request e-Authorization from Payer• Communicate to patient on payer & DHA messages• Dispense medications to patient (e-authorization means guaranteed payment for pharmacy)

PayerShall provide real time responses to eRx at both physician office and pharmacy

• Clinical Checks on eRx (considering patient history)

• Eligibility & Benefit Coverage

DHAShall provide

• Specification for the initiative• Facilitate transactions through eRx Hub (at DHPO)• Free of charge solutions for pharmacies and physicians to manage eRx• Training for providers and payers• Monitor through the Drug Analysis and Control System (dacs) and

intervene as needed

Insured PatientsShall get

• Reduced medical errors in prescribing and dispensing• Reduced waiting time at pharmacy• eRx information on Patient Portal

Pharmacy

Physician

DHPO

Payer

eRxPharmacyModule on ProviderLink or ext. provider system

eRxPhysicianModule onProvider Link or ext. provider system

Authorizations & Claims

eRx Hub

Patient

dacs

Part of the Patient Portal

AdjudicateE-Authorization

Payers/TPAs of the vast majority of members in Dubai have the technology implemented in Dubai or elsewhere in UAE to adjudicate authorizations in seconds.

Providers in Dubai shall be offered FREE of Charge tools to call for e-Prescriptions / e-Authorization in seconds at physician office and pharmacy. Else can integrate in their systems. (Most pharmacies are doing real-time authorizations with a number of payers)

System Readiness

Benefits

• Prescribing Mistakes• Dispensing Mistakes• Fraud• Waste• Abuse• Wait time @ pharmacy• Pharmacy-physician calls• Claims submission time

• Patient Safety• Health Outcome• Information Accuracy• Effective Communication• System Efficiency• Control on Resources• Transparency

decrease increase

Pharmacy Real-Timee-Authorizations, and claimingwith Payers

Phase I

Phase

II

Phase III

Physician Real-Timee-Checks with Payersand posting eRx

Pharmacy Real-TimeDownload eRx, request e-Authorization & claim

July 1, 2013

October 1, 2013

January 1, 2014

Voluntary

Voluntary

Mandatory

Process Time Average

less than

60 seconds

less than

60 seconds

less than

60 seconds

Physician Real-Timee-Checks with Payersand posting eRx

Pharmacy Real-TimeDownload eRx, request e-Authorization & claim

less than

30 seconds

less than

30 seconds

eRx Initiative - Implementation in Dubai

Functionalities Deployed

For information on the e-Prescription Initiative

• Orientation• Documentation• Process• Schema• Training

Vist eClaimLink.ae portal

Dubai

Leading to implement e-Prescriptions regionally and one of the leading globally in this regard

towards superior healthcare systemfor its population

Updates

Medical e-Authorization

• DHPO is ready for such transactions.

• Free tools for providers are available on eClaimLink.

• DHA encourage Providers and Payers to use it by September 1, 2013.

Tariff Plans Timelines

May, 1, 2013 – All providers are expected to submit a full standard price list to the payers for approval.

July, 1, 2013 – All payers are expected to submit the tariff plan comments.

September, 1, 2013 – All payers and providers are expected to have fully approved standard tariff plans.

Non-standard code shall be discontinuedfor CPT/CDT/HCPCS/DSL as part of observation section

For claims with service dates in September 1, 2013 onward

i PROMeS

Health Insurance Partner Relation Management e-System

Feedback, Complains, Suggestions or Complements

Insurance Product Registration

All insurance products offered by insurance companies shall be registered by payers.

followed by

Person Register

Inspection System

Fraud is a crime defined as an intentional deception made by a person with the knowledge that the deception could result in some unauthorized benefit.

Abuse/waste is a Provider practices that are inconsistent with fiscal or medical practices, and result in an unnecessary cost to Health system.

Why?The health insurance inspection policy will allow a standard recognized process/procedures for inspection of facilities if fraud/abuse/waste behavior is suspected or noticed.

Fraud & Abuse can account for up to 25% of annual health care costs in unregulated systems.

From the monitoring tools that are used in this regard (already active):• eClaimLink Analytics• CEED• more to come…

backed by law enforcement

A localized edit engine to validate medicalcoding relationships.

These edits are intended for• Providers to code better,• Payers to adjudicate wisely,• Authorities to analyze and monitor

claims effectively.

12+ Million Edit Combination

Medical Necessity/Cross Coding Checks

ICD – CPT, ICD – HCPCS, ICD – CDT

Coding ChecksBundling, mutually exclusive coding, duplications, maximum allowed frequencies, services relationship errors, encounter related edits.

CEED covers:

-Diagnosis Codes (ICD-10-CM)-Procedure Codes (CPT)-Disposable and Consumables (HCPCS)-Dental Codes (CDT)-Dubai Service List (DSL)

Drugs are covered in the e-Prescription Project

Coding Edit Engine of Dubai - CEED

Effective tool to detect and reduce

error, waste, fraud and abuse

built on US standard coding edits,Supported by DMCC for complains

In Focus Study

Number of

CPT/HCPCS/CDT

has Alerts/Reviews

21%

Net (AED) of

CPT/HCPCS/CDT

has Alerts/Reviews

26%

Mainly their MedicalNecessity Questionable

Mainly their MedicalNecessity Questionable

Provider can see their scores at their Dashboard when they log into their accounts on eClaimLink

(a study done on Feb-March data)

Example for issues detected by CEED

2484 AED

Examples for issues detected by CEED

For such issues detected by CEED

• Payers can reject based on CEED.

• Providers can use CEED to enhance quality of coding.

• Technical complains on CEED’s ‘Alerts’ can be directed to DMCC.

• Providers with consistent similar trends or other valid reasons to expect fraud, waste or abuse, are subject for inspection by DHA.

Issues on eClaimLink

• A number of facilities are submitting in the name of other facilities (mainly same group).• Each facility should use its own account to claim, not the group’s.

• A limited number of facilities and payers are not e-claiming as mandated by DHA: ALL providers should claim only through eClaimLink to ALL payers.• Official warnings shall be communicated to non-compliant

organizations soon.

• Facilities management are not getting the latest updates.• All eClaimLink admin users should communicate to their

management the latest updates regularly. • Send eClaimLink the management contact info to directly

communicate with them.