HealthCare Management system

Transcription

1 HealthCare Management system Another Quality Solution by: Tel : (+962) Fax: (+962) Amman P.O. Box Jordan [email protected]

2 Past, Present & FACT It is no secret that today, right now; there is a pressing need for medical care. Populations are growing, illnesses and diseases are becoming more prevalent, and public healthcare systems are falling short. Today, more and more governments are relying on private insurance companies to run national medical programs. This has become an international tendency, and is not truer than in the Arab world. In just 5 years, the healthcare insurance industry, in the Middle-East and North African regions, has grown exponentially. Moreover, health insurance has a high usage rate; any individual with a healthcare plan will use it at least once during the course of the contract. As such, health insurance administration requires an army of individuals. But despite that, the business lacks control, and there is much waste in claims compensation and much abuse of the system. The exponential growth expected in the market is worth millions of dollars in new business, and insurance companies have to be prepared for it. Historically, the insurance sector has been one of the challenges for the Middle East but always a clear source of huge potential. Those who do not arm themselves with the proper tools will lose potential clients, and see a drop in existing business. Health insurance management companies face fierce competition, and without the correct software solution risk finding themselves with no coverage. In 1998, a company foresaw the opportunities in the insurance industry, and had a vision to develop state-of-the-art solutions that will keep pace with industry changes and comply with changing environments effortlessly. And so, FACT was established. And with the strong team behind it, FACT quickly proved itself on the scene, and in no time became an industry pioneer in the areas of insurance, banking and Islamic finance software development. With that vision in mind, FACT put together a team of insurance industry professionals, highly qualified consultants, and certified technical specialists and systems experts to create an insurance system. Over 25 years of market experience and a clear look into the future poured into the creation of Al-Haris TPA. Al-Haris TPA is a comprehensive fully integrated healthcare management system that manages the relationship between the insurance company, the providers, the insured and the re-insurance company. Al-Haris TPA requires a small number of staff to run the product, reduces time and effort needed to process claims and payments, verifies claims validity automatically and catches false claims, thus eradicating unnecessary payments. Al-Haris TPA offers great benefits to the bottom line. It saves on administrative costs, personnel costs, and disbursement costs. In summary, Al-Haris TPA provides excellent technical results by combining, outstanding underwriting and product design, along with exceptional network management, top of effective claims and case management, and extraordinary MIS and data management.

3 Managed Care Structure Health Care Third Party Administration (TPA) companies offer high-level managed health insurance operations tracking in order to optimize the returns of the insurance business. It provides a variety of services to the medical care plans to implement and operate it. Health Care Third Party Administration (TPA) companies are the connecting link between the Insurance and/or the re-insurance company, the health care provider and the insured member. Al-Haris TPA Team At FACT, a team of insurance business and IT experts developed Al-Haris TPA solution to provide the highest quality of cost effective medical care in the most appropriate health care setting. Understanding health insurance and its managed-care market, FACT launched the comprehensive Al-Haris TPA solution. Al-Haris TPA automates the operations of TPA companies, providing full management solution. Business Benefits: Al-Haris TPA controls the redundancy to adhere to the rising need of performing a single logical preserving information consistency, Al-Haris TPA high level of security protects confidential information ensuring privacy and grant access only to authorized users, Al-Haris TPA features real-time and accurate information at enterprise level leading to availability of up-to-date information, Al-Haris TPA provides reporting and tracking capabilities, with full view on current business status and supports the inspection of the trend over a long period of time,

4 Al-Haris TPA General Features: 1. Secure Security is considered critical from business and ethical perspectives; greatest attention was given to this feature. Security is provided through different layers: a) Privileges: Al-Haris TPA handles groups and user profiles / roles; offering personalized menus and ensures that users perform only needed and permitted operations within predefined functions. b) Audit Trails: Users' interactions are recorded in a log file that provides full audit trails. c) Data Integrity: Al-Haris TPA updating capabilities are designed to provide maximum data integrity and simple recovery procedures in case of failure without risky interventions of solution administrator. d) Platform Security: Besides the products and options that let the administrator easily define who has access to the data and who has not (Label Security, Virtual Private Database, Enterprise User Security), Al-Haris TPA ensures there are no back doors to malicious code and hacker's attacks. 2. Bilingual - Authorized users can define new labels in additional languages and make it available to users, - Al-Haris TPA manages simultaneously two data fields' languages for codes and parameters tables as well as the customer's database. - Right to left writing capability (such as Arabic) is provided as native language. 3. Integrated All modules and functions are automatically interrelated and share the common information. Data entered by operator is never fed twice; Al-Haris TPA allocates and distributes information to all related sub-solutions and modules. 4. Flexible Al-Haris TPA uses extensive codes and parameters that make the solution very flexible; screen titles, labels of fields/buttons and error messages are provided by setup package module. 5. Interactive Al-Haris TPA works interactively with users through: 1. Menu-driven capability, including reporting and batch jobs 2. Inquiring facilities at any level, at any time 3. Validation dialogue at data captures level. 6. Ease of Operations Al-Haris TPA offers Graphical User Interface (GUI), designed to be operated by end users, even without technical background, the Help feature and pop up lists are available to end-users at fingertip, standardized provide the same meaning throughout the entire solution.

5 7. Efficient, Feasible and Reliable Al-Haris TPA default values accelerate entering new data. Conditions and validations on processed data is provided to ensure the correctness and accuracy of entered data thus decrease the time needed tracing and validating errors Al-Haris TPA offers a rich set of reports that speed up the work and improve the outputs of the company documents; Al-Haris TPA focuses on user's time optimization. Technical Features: Al-Haris TPA is designed using ORACLE latest technology web-based; operates on Windows, Linux, and UNIX; supported by all hardware configurations, from small single processor machines to high-end SMP environments, Scalable, Easily interfaced with third parties, provides fault tolerance from hardware failures or planned outages, Lower total cost of licensing associated with deployment. Al-Haris TPA provides storage structures for efficient query processing, Al-Haris TPA offers backup and recovery in case of disasters, Modules 1. Accounting All accounts and financial transactions maintained by Al-Haris TPA in; the Chart of Accounts with unlimited number of levels, Daily Transactions, Accounts Balances, and Transactions Vouchers. The accounting solution is a dual solution that operates for both TPA and insurance company operation.

6 2. Security Al-Haris TPA users are defined according to area of specialty and granted solution accessibility. Accordingly, several security levels can be implemented according to functionalities: Group Security and Login Sheet. This facility helps protecting the confidentiality of the insurer information and controls the user's transactions. It also provides Al-Haris TPA administrator with the ability to control the usage of the solution out of the working hours. 3. Setup This module defines the general organizational structure by defining the solution menus and functions of groups, in addition to defining employees, users and general parameters of the package that enable to establish unified interfaces. Health Insurance Codes setup: enables the user to set up the structure and coverage rules of diverse health insurance products; the configured insurance codes will later be used in producing policies and endorsements, and automatically calculate policy premiums and claims costs. Providing the following configurations: Disease Names and titles*, Diseases Classes, Disease Definition, Procedure Information, Class of Business, Benefits and Services, Body Mass Index, Questionnaire and Fees. * pre-defined according to the CPT, RAD, LAB and ICD10 disease definition. 4. Network Al-Haris TPA supports Provider Network Management by a comprehensive database and directory; user can define provider's type and codes, specialties for each type, and keep record of valuable information of each provider, Al-Haris TPA administrates the relationship with providers by supplying agreements support methods between the TPA Company and the providers that allows multiple networks per provider and multiple contracts per provider, agreements cancellation, and agreements renewal. It also provides a follow-up controls mechanism to track fraud and abuse. 5. Medical Plans The capability of grouping benefits together offering them as one piece of coverage in a plan; managing the calculation of the premium on benefit plan level, which allows the user to determine the number of forms for each member, the waiting period, the reimbursement period and the class. It is also allowed to determine annual limit for benefits in the plan, and the case limits, co-payment and deductible for services. 6. Customer Al-Haris TPA customer module enables users to perform a follow-up on different types of customers (insurance companies, brokers, etc).

7 7. Insurance Companies and Agents Al-Haris TPA insurance module manages the relation between the TPA Company from one side and Insurance companies, Brokers, and Other TPA companies from the other side. Cards: Insurer Cards may be created and printed through Al-Haris TPA. 8. Reinsurance Al-Haris TPA reinsurance module supports the administration of reinsurance treaties of all types: quota share, excess of loss, stop loss, and proportional treaty. It helps fulfill reporting and accounting obligations towards reinsures in a simple and cost effective manner, 9. Production Al-Haris TPA offers a comprehensive policy and member management, by supporting production operation throughout the life cycle of a policy, from issuance to endorsement and renewal. Individual and group policies are effectively managed by the same solution platform, Al-Haris TPA allows the user to issue a policy for groups or individual members using plans early defined. The policy can use multiple plans, but a single plan for each member with the ability to choose: the standard, premium loading, member specific exclusions, waiting period and deferment (postpone). Production accounting: all accounting transactions pertaining to the insured, such as invoicing and settlement, are processed through this module. Invoices are automatically created and dues owed or owing are automatically calculated and payments are tracked. 10. Claims Al-Haris TPA claims module is a complete claims operation starting from registration transactions into data entry up to the auditing and settlement transaction; Al-Haris TPA claims module enables the TPA Company to adjudicate claims and perform all ancillary functions. It can process all types of health insurance claims including Network, Direct, and Reimbursement Claims. It automatically determines the amount payable to the provider based on contracts. Claims accounting: All accounting transactions pertaining to the providers and the insurer are processed through this module. Payments are tracked and credit and debit notes are issued. All amounts owing and owed are automatically calculated and tracked. 11. Pre-Approval Al-Haris TPA supplies the user with the tool to handle pre-approval cases of both types: in-hospital pre-approvals, such as hospitalization for more than 24 hours, day case, and emergency treatments, and out-hospital pre-approvals such as clinic procedures, major pharmacy claims, expensive diagnostic tests (MRI, CT, Endoscopies, etc), and physiotherapy, Pre-approval module has a referrals relation operation whereby all interactions with the medical facilities are being recorded.

8 Al-Haris TPA Claims Validation: Active/inactive, Network provider/not a network provider, Blacklisted provider, ICD waiting period, procedure cost either in points or fees, discount or overloading given for the provider on this specific procedure, the annual limit and number of times allowed of the medical procedure for the member, medication coverage for the member, The module has full-automated audit functions that run a large number of checks before giving a pre-approval. 12. Reports and Queries Al-Haris TPA provides a rich set of reports and query screens. Any report or query concerning any operation in the medical insurance can be extracted or developed. It is worth mentioning that this set of reports and queries are updated depending in the requirements of the TPA Company. In addition, there shall be the ability to draw charts directly from the solution according to the desired report or query. Underwriting in general is the process when the insurer determines whether a risk is acceptable or not.