e-prescription Initiative for Dubai Insured Population
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1 e-prescription Initiative for Dubai Insured Population and Update May 5, 2013
2 Components Support Services Committees : DMCC, EDSC Regular Training Sessions & Support Call Center In development, release planned in 2013 Developed but not active yet as of end of Q1.2013
3 In Numbers (claims till April 30, 2013) 1,561 Facility Registered 55 Payer/TPA Registered Person Trained Started eclaims in June 1, 2012 Only Enaya ALL Providers and ALL Payers to eclaims starting January 1, 2013
4 Number of Monthly Claims Submitted on eclaimlink in K Claims 190 M in Gross 165 M in Net 15 M in P.S. as of May 1, 2013
5 In Numbers (claims till April 30, 2013) 3.8 million Activity Claimed 2.1 Diagnosis Code Used million 6,647 Physician Provided Services 9,571 Unique Activity Conducted 16,995 Unique Diagnosis Codes Used 50 Payer/TPA Received Claims
6 Activity Types Net Value Distribution Dental 3% Services 23% Drug 23% CPT 47% HCPCS 4% Net Distribution by Activity Type
7 e-prescription Initiative for Dubai Insured Population
8 e-prescription Process in Dubai 30 seconds average 30 seconds average Outpatient Setting
9 Physician Shall 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 Pharmacy Shall 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) Payer Shall provide real time responses to erx at both physician office and pharmacy Clinical Checks on erx (considering patient history) Eligibility & Benefit Coverage
10 DHA Shall 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 Patients Shall get Reduced medical errors in prescribing and dispensing Reduced waiting time at pharmacy erx information on Patient Portal
11 System Readiness 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) erxpharmacy Module on ProviderLink or ext. provider system Part of the Patient Portal Pharmacy Authorizations & Claims Patient erx Hub erxphysician Module on Provider Link or ext. provider system dacs DHPO Adjudicate E-Authorization Physician Payer
12 Benefits decrease Prescribing Mistakes Dispensing Mistakes Fraud Waste Abuse Wait pharmacy Pharmacy-physician calls Claims submission time increase Patient Safety Health Outcome Information Accuracy Effective Communication System Efficiency Control on Resources Transparency
13 erx Initiative - Implementation in Dubai Phase I July 1, 2013 Voluntary Functionalities Deployed Pharmacy Real-Time e-authorizations, and claiming with Payers Process Time Average less than 60 seconds Phase II October 1, 2013 Voluntary Physician Real-Time e-checks with Payers and posting erx Pharmacy Real-Time Download erx, request e-authorization & claim less than 60 seconds less than 60 seconds Phase III January 1, 2014 Mandatory Physician Real-Time e-checks with Payers and posting erx Pharmacy Real-Time Download erx, request e-authorization & claim less than 30 seconds less than 30 seconds
14 For information on the e-prescription Initiative Orientation Documentation Process Schema Training Vist eclaimlink.ae portal
15 Dubai Leading to implement e-prescriptions regionally and one of the leading globally in this regard towards superior healthcare system for its population
16 Updates
17 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.
18 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. For claims with service dates in September 1, 2013 onward Non-standard code shall be discontinued for CPT/CDT/HCPCS/DSL as part of observation section
19 i PROMeS Health Insurance Partner Relation Management e-system Feedback, Complains, Suggestions or Complements
20 Insurance Product Registration All insurance products offered by insurance companies shall be registered by payers. followed by Person Register
21 Inspection System backed by law enforcement 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
22 Coding Edit Engine of Dubai - CEED A localized edit engine to validate medical coding relationships. These edits are intended for Providers to code better, Payers to adjudicate wisely, Authorities to analyze and monitor claims effectively. built on US standard coding edits, Supported by DMCC for complains Effective tool to detect and reduce error, waste, fraud and abuse 12+ Million Edit Combination Medical Necessity/Cross Coding Checks ICD CPT, ICD HCPCS, ICD CDT Coding Checks Bundling, 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
23 In Focus Study (a study done on Feb-March data) 21% Number of CPT/HCPCS/CDT has Alerts/Reviews Mainly their Medical Necessity Questionable Provider can see their scores at their Dashboard when they log into their accounts on eclaimlink 26% Net (AED) of CPT/HCPCS/CDT has Alerts/Reviews Mainly their Medical Necessity Questionable
24 Example for issues detected by CEED 2484 AED
25 Examples for issues detected by CEED
26 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.
27 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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