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.
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