COLLABORATIVE ENHANCEMENT OF BUSINESS PRACTICES

Transcription

1 COLLABORATIVE ENHANCEMENT OF BUSINESS PRACTICES October, 2008 Edited by: NEXtCARE Arab Gulf Health Services LLC. Dubai United Arab Emirates

2 Dear All, It has been a rewarding experience, during the past few years, for us to administer beneficiaries insured by you. Together we have succeeded in offering a respectable level of service to members using their health benefits and accessing our network of health providers. We have always strived to improve the service we offer to your clients, as well as enhance processes we both use to collaborate & communicate through. It is in this regards that we come to you with this manual for a collaborative approach to enhance our business practice. This brief manual was established based on feedbacks from our operational teams and based on various grievances we received from beneficiaries & providers. This manual contains, to our best knowledge, enough information to enable both our teams perform their daily operations in a smooth and structured way. It also gives us the ability to service your clients in a better way avoiding any unpleasant surprises when availing service from the network of provider s. This is still at its early versions, knowing some areas might not apply to you, feedback and comments are more than welcome. We strongly believe that a mutual partnership, into making this manual a comprehensive document, is more than beneficial and will reflect positively on your clients by helping us achieve higher level of service. NEXtCARE Team 2 of 16

3 INDEX Introduction Standard Card Format Obligatory Fields to be mentioned on the health card Optional Fields which can be added on the health card Special Conditions VIP Members Card Sample TATSH System Procedure Product Creation Contract Creation in TATSH Important Notes 9 3. Network of Preferred Providers UAE s Local Network 9 A. NEXtCARE Network Agreement 10 C. Network Exclusions List 11 C. Conditions not accepted at certain providers 11 C. NEXtCARE HEALTH CHECK UP PACKAGE How does it work? 12 Executive Package Details.. 12 Standard Package Details.. 12 List of polyclinics that accept healthcare check up vouchers 13 Check-up Procedure Regional Network International Network Visiting Doctors Reimbursement Claims at Network Providers Inclusion and nomination process...15 Nomination request from Insurance companies 15 IMPORTANT NOTES. 15 Top Reasons for Denial of Application.16 3 of 16

4 Introduction When a beneficiary visits a provider, the first action that takes place in that visit is the presentation of the medical card. If the information on the card is either not clear, or nonstandardized, this may cause confusion within that visit. The issue may escalate leaving the beneficiary frustrated, and at times without cooperation from the providers. To avoid such possibilities, NEXtCARE has highlighted areas of improvement, and created a standard for card formatting. 1. Standard Card Format 1.1 Obligatory Fields to be mentioned on the health card: a) Insurance Company Name and Logo b) Policy Holder Name c) Name of the insured member. Make sure that the spelling of the name is exactly as entered in TATSH. The name in TATSH only accepts 30 characters and should only consist of First name, Father s name and Family name. If those names exceed the 30 characters only the first and last name to be used. d) Card number: A 16 digit alphanumeric code is generated by TATSH. This number remains with the member on each and every policy renewal to ensure that his medical history (file) is stored under this number. In case of card loss a card replacement endorsement will be required. e) YOB: Year of birth f) Network: No other initials or network names to are be used other than the standard nomenclature mentioned below, the same has been circulated to all the providers under NEXtCARE: GN+ Initials must be mentioned on the card for General network including American Hospital. GN Initials must be mentioned on the card for General Network RN Initials must be mentioned on the card for Restricted network RN2 Initials must be mentioned on the card for Restricted Network 2 Special Network: In case a certain provider is to be added from a different network category to any of the standard networks, the name of this provider in full must be printed on the card next to the network. NOTE : Any deviation from the existing network structure must be approved by NEXtCARE subject to the acceptance of the Healthcare provider. For Example: Network: RN+ Welcare Hospital. Additionally, a soft copy of this card must be forwarded to the network department to convey the same to this provider and ensure direct access for those members. 4 of 16

5 *REMARK : Network as shown on reverse is not acceptable by the providers. This selected network can not be administered nor controlled. g) Class: Specifies the category of the room for in-patient services Classes can be: Private, semi-private & Ward Important note: Most providers only offer private rooms. In cases where the provider does not have a semi-private room or ward, the member is obligated to pay the difference between the cost of the private room and what is covered under the scheme. h) Additional Benefits A- Maternity: i. Maternity: Yes is to be printed on the card when maternity benefits are covered on direct billing. ii. Maternity: Yes (AUH) is to be printed on the card when maternity benefits are covered on direct billing for all Abu Dhabi policies. iii. Maternity: Yes (Reimb) should be printed, if maternity benefits are covered on Reimbursement only iv. Maternity: No is to be printed on the card when there are no maternity benefits. B- Dental i. Dental: Yes is to be printed on the card when dental benefits are covered on direct billing. ii. Dental: Yes (Reimb) should be printed, if dental benefits are covered on Reimbursement only. iii. Dental: No is to be printed on the card when there are no dental benefits. C- Optical i. Optical: Yes is to be printed on the card when optical benefits are covered on direct billing. ii. Optical: Yes (Reimb) should be printed, if optical benefits are covered on Reimbursement only. iii. Optical: No is to be printed on the card when optical benefits are not covered on direct billing. i) Deductible: If the amount is mentioned alone, it is understood by the providers that the deductible is to be applied on consultation. However, if a deductible is for a specific service, the same must be reflected on the card clearly to the provider. For example: Ded: AED 50 (Ded: AED 10 for Diagnostic) j) Expiry date: Should reflect the expiry date of the policy based on the following format (DD/MM/YYYY). 5 of 16

6 k) NEXtCARE logo and contact details preferably be printed on the front or at the back of the card, preferably on the back (Stickers of NEXtCARE logo are not practical and can not be used) 1.2 Optional Fields which can be added on the health card a) Member s photos: If the member s photo is required to be printed on the card, a passport size photo with preferably white background in JPG format must be provided to NEXtCARE (If applicable). The photos must be scanned and organized in order based on the employee name and ID number. b) Plan/Category: this is an optional field to indicate the plan name if any. c) Co-participation: If the percentage is mentioned alone it is understood by the providers that the co participation is to be applied on all services. However, if a Coparticipation is for a specific service the same must be reflected on the card clearly to the provider. For example: Co-par: 30% for pharmacy 1.3 Special Conditions a) When there are sub-limits on services other than the additional benefits, a note informing the provider that pre-approval is required is mandatory. Pre-approval required for every Consultation and Pharmacy for example in cases of Individual policies. Pre-approval required for Pharmacy in case the sub-limit is only on medicines. *Please note that if the comments on the cards differ from the above, it must be approved by NEXtCARE before printing. The reason for the above notes to providers is to enable us monitor the sub limit and prevent exceeding it. Important Note: Cards requesting pre-approvals are not accepted at some busy providers, such as Al Zahra hospitals and all New Medical Center Hospitals. NEXtCARE has attempted to negotiate with these hospitals in order to terminate this practice. The providers however were not receptive, and to avoid disruption of services to our members, NEXtCARE has accepted such practices. It is advisable that you sign a short fall agreement with your clients to cover any exceeded limits. b) Policies administered by NEXtCARE for In-patient only, IP ONLY or In-Patient only must be clearly printed on the card. If the Insurance Company is offering an HMO scheme for out-patient services it is recommended to have a separate card for this. c) Any covered service/benefit that is mentioned in NEXtCARE s Standard Exclusion list (as attached) must be clearly printed on the card to show that the 6 of 16

7 member is indeed eligible for these services. This happens in cases where the service / benefit are normally excluded in most policies. For example: Psychiatric is to be pre-approved, Work related Covered. * Please note that before printing cards with the above statement, a soft copy of the card must be sent to NEXtCARE for approval. 1.4 VIP Members For VIP members the cards must mention VIP in bold font at the front in a clear readable location and the same must also be marked under DMP (Distinguish Management Program) in TATSH*. All treatments shall be covered even those mentioned under the exclusion list. Providers are informed that Pre-approval for outpatient services is not required for VIP members. The same must be committed by the insurance companies. * Please refer to the TATSH Production Manual for specific instructions 1.5 Card Sample The below sample is for reference purposes only. Front Side Back side 2. TATSH System Procedure 2.1 Product Creation A product represents the packaging of Plans offered by the Insurer and selected by the Contract holder in the Application Form. For more details on how to create a product on TATSH, please check the production manual under downloads in TATSH main menu. 7 of 16

8 We highly recommend using a standard product naming method on TATSH which is as follows: Hosp) (a) (b) (c) (d) (e) BASIC ( L:100K,Ded:50( PHY20% copar) Mat, Opt, Dent, Assis, Vac, Vit, RN+ Welcare a) Geographical Area : Local: Inside the UAE Basic: UAE + Arab Countries+ India Subcontinent + SEA (South East Asia) Universal: World wide excluding USA and Canada Universal Plus: World wide including USA and Canada b) Aggregate Limits c) Deductibles and Co participation d) Additional Benefits : Maternity (Mat), Optical (Opt), Dental (Dent), Assistance (Assis), Vaccinations (Vacc)& Vitamins (Vit)} e) Network 2.2 Contract Creation in TATSH The Contract or insurance policy whereby the Insurer, subject to the Application Form/s, Terms, Provisions, Limitations, Exclusions and other conditions provided herein, guarantees the payment of the benefits set forth in the Contract Schedule and Applicable Scope of Coverage Schedules. (please refer to insurance manual in TATSH for definitions) 1. Remember to always upload the policy wording (Schedule of Benefits) on the master contract page immediately, even before validation. 2. Make sure that effective date of the policy and all other general information is correct (we suggest using the following date format DD / MMM / YYYY). 3. Highlight any important notes under the contract notes. 4. Make sure that the contract tariffs (premiums) are correctly added. 5. Add categories and category privileges. 6. Upload the members list with all the required information (TATSH will except max 2000 members on each sheet). 7. Flag DMP (Distinguish Management Program) if member is VIP. 8. Validation of contracts: Make sure all the information and premiums are correct before validation. Once a policy is validated no changes can be done to the contract. This can lead to incorrect and/or insufficient benefits being noted on 8 of 16

9 TATSH which can in turn lead to denial of claims and incorrect computation of premiums. 9. Validation should be done within 3 working days. If Validation is not done members status will be inactive in the system. In addition, to that the policy can not be viewed by call center agent and claims center doctor. 2.3 Important Notes a) The upload of the policy (Schedule of Benefits) is compulsory for each new / renewal contracts. This creates easy access for the Call Centre to quote benefits while taking calls, and the Claims Center in pre-approving and processing claims. b) The validation of the contract must be done within 3 working days. If not done the insured member will be inactive and the Call Centre will not be able to view the policy. Therefore NEXTCARE agents will not be able to assist the insured member with any queries or approvals. c) After validation no corrections or modifications can be done on the system. For that reason always double check the information before validation. d) Upload of policy can not be done after validation. Therefore, make sure that the policy has been uploaded before the validation. e) NEXtCARE agents will always depend on the information/data entered in TATSH. For example: If the card is wrongly printed with GN and the contract is showing RN, then the agent will follow the information in the system and deny the direct billing (in cases pre-approval is required). We recommend that such errors should not occur to avoid any inconvenience to the beneficiary. f) To overcome any variation in the amount endured by the member, it is recommended to mention the room & board limit for inpatient services in each policy. g) In accordance with the GAHS policy for Abu Dhabi (including Al Ain) maternity benefit is covered up to the aggregate limit. For that reason no pre-approval is needed for all outpatient maternity services. For any problem related to Tatsh such as (abort jobs, slow connection and disconnection) please send an directly to our 24 hours support address ([email protected]) and keep us Cc d for follow up.. 3. Network of Preferred Providers The Network department will sent local and regional network list via on monthly basis to the payers head office. The head office shall be responsible to circulate the network list internally, among branches, brokers and clients. 3.1 UAE s Local Network 9 of 16

10 NEXtCARE has 4 main Preferred Providers Networks, as follows 1- GN+: General Network Plus (General Network including American Hospital) 2- GN: General Network 3- RN: Restricted Network 4- RN2: Restricted Network 2 It is important to highlight the below points to your clients along with the Network list to overcome any inconvenience caused to your insured members. IMPORTANT NOTES: - The list of medical facilities and specialties per facility is not static and may be subject to change. - NEXtCARE reserves the right to update this list at anytime, - Treating physicians at certain facilities within NEXtCARE s network do not comply with the standards of NEXtCARE, thus no direct billing arrangement is in place with that physician. Please inform you client to confirm this with the facility before availing the service. A. NEXtCARE Network Agreement: NEXtCARE signs a network agreement with all providers on behalf of the payers. However, there are essential healthcare providers in the market where the Insurance Company has to be involved in the network agreement. The wordings of such tripartite agreements are prepared by the healthcare providers themselves. Healthcare providers that require tripartite agreements (NEXtCARE as the TPA, Insurance Company as the payer and the Healthcare provider) are: 1- American Hospital- Dubai 2- Al Zahra Hospital (and affiliated Medical Center) Insured members are not accepted on direct billing at those facilities until the tripartite agreement is signed. Signing the Healthcare Provider s agreement consequently means that there are special conditions and procedures, which are to be followed, that might be different from NEXtCARE s network agreement. American Hospital: Specific procedures and conditions that do not comply with NEXtCARE s network agreement are as follows: 1. Out-patient services are not monitored. For Example: No pre-approval is obtained for maternity antenatal services. Exclusions are not monitored on out-patient consultations, hence to be considered as covered. 2. No free follow up on consultations. 3. Pharmacy pre-approval is obtained only for medications prescribed for more than one month. 10 of 16

11 4. Vaccinations are excluded for all policies. Policies that cover these services, the members will have to pay and recover the amount through re-imbursement. 5. Hormone Replacement Therapy, Oral Vitamines and Enzymes are in the American hospital exclusion list; therefore no pre-approval shall be taken. Groups that cover these services will have to pay and recover the amount through reimbursement. 6. Results and reports are only submitted for Inpatient claims. Al Zahra Hospital: Specific procedures and conditions that do not comply with NEXtCARE s network agreement are as follows: 1. Only out-patient services exceeding the net value of AED 1000 will be subject to pre-approval. 2. Medicines may be prescribed for a maximum period of 30 (thirty) days at a time without pre-approval, drugs for chronic ailments may be prescribed for a maximum period of two months without pre-approval. 3. Consultation fee for a single out-patient follow up visit falling within one week of the initial visit will not be charged provided that such visits are with the same doctor and for the same illness. If the second follow up visit falls within 7 days, it shall be considered as a new consultation and therefore deductibles and charges apply. 4. Pre-approval for individual policies and policies with sub-limits are not accepted on direct billing despite being mentioned on the card. B. Network Exclusions List There are a few healthcare providers in NEXtCARE s network that do not accept direct billing for a particular department/doctor at their facility. The healthcare provider informs the member before giving the service about this exclusion. In case the member insists on visiting the concerned department/doctor, the member will have to pay in cash and claim on reimbursement basis. NEXtCARE shall process the reimbursement claim as per the policy terms and conditions. Healthcare providers that have such exclusions are: 1. American Hospital -Dermatology department 2. Emirates Hospital - Dental Department 3. Dubai London Clinic- Dental and Maternity services 4. MEDCARE Hospital- Dr. Chris Whatley and Dr. Marc Sinclair Whenever the network provider excludes a certain Doctor/service from the direct billing agreement, this shall be noted and updated on the network list accordingly. C. Conditions not accepted at certain providers: 11 of 16

12 Pre-approval required for every consultation and Pharmacy is a condition that not all healthcare providers accept. Healthcare providers that do not accept cards with this statement are mostly busy hospitals like Al Zahra Hospital & affiliated medical center, NMC hospitals, Iranian Hospital and American Hospital. Individual policies and policies with low sub-limits that have this statement printed on their cards are not accepted on direct billing at the mentioned providers. Insured members must be advised of the same. D. NEXtCARE HEALTH CHECK UP PACKAGE: How does it work? This package is designed for the Insurance Companies who offer their customers, the option of a health check up once or twice per year (or as requested by the client). The services under this package were negotiated by NEXtCARE with a limited number of providers, in order to meet a certain amount of visits at their end and to ensure the package cost is the lowest possible. NEXtCARE has designed two different types of packages to fit the needs of various clients. 1. Executive Package Details This package contains the following services: 1. Electrocardiogram (ECG) 2. Blood Pressure Screening 3. Complete Blood Count (CBC) 4. Erythrocyte sedimentation Rate (ESR) 5. Fasting Blood Sugar (FBS) 6. Blood Urea Nitrogen (BUN) 7. Serum Creatinine 8. Total Cholesterol 9. Lipid Profile 10. Liver Function Tests 11. Urine Analysis 12. Stool Analysis 13. General Tests like VDRL 14. Chest X-ray 15. Genital and Rectal Examination 16. Complete Physical Examination (including taking of height, weight, pulse/heart rate, respiratory rate) 2. Standard Package Details This package contains the following services: 1. Physical Examination by General Physician 2. Electrocardiogram 3. Blood Sugar 4. Complete Blood Count 12 of 16

13 5. Erythrocyte Sedimentation Rate 6. Blood Urea Nitrogen 7. Creatinine 8. Total Cholesterol 9. Urine analysis 10. Stool Exam To assist the facility in rendering the best services, members are advised to book an appointment prior to checking in. List of polyclinics that accepts the healthcare check up vouchers Provider City Tel Address Al Noor Polyclinic Dubai (04) Naif Street, Deira Al Noor Polyclinic Satwa Dubai (04) Bakhita Al Garwan Bldg, Opp. Al Maya Lal's Super Market, Satwa Al Rashidiyah Al Noor Polyclinic Cosmopolitan Medical Centre Dubai (04) Behind Bin Sougat Centre, Rashidiya Dubai (04) Khalid Bin Al Walid St., Al Mashreq Bank Bldg, 2nd Floor, Bur Dubai W. Wilson Medical Centre Sharjah (06) Al Borj Bldg, 1st Floor, Taavon Rd Doctors Medical Centre Sharjah (06) nd Floor, Above Thomas Cook Al Rostamani, Rolla Rd Middle East Specialized Medical Centre Abu Dhabi (02) Opposite Emirates Media, Murror St., Mushrif Check-up Procedure 1. Beneficiary calls Provider and pre-schedules appointment for HealthCare Check-Up. 2. Beneficiary is attended to promptly. 3. Beneficiary presents HealthCare Check-up Card. 4. Receptionist collects HealthCare Check-Up Card and stamps with provider stamp. 5. Required lab tests are collected and results established by licensed professionals. 6. Examination with licensed General Physician is conducted. 7. Beneficiary Education and Consultation Conducted. 8. Copy of test results given to Beneficiary. 9. HealthCare Check-Up cards are separated from General Medical Claims and sent to NEXtCARE on a monthly basis, labeled HealthCare Check-Up Claims for easy identification by NEXtCARE. 10.Payment of AED 50 per card returned to Provider within 10 days. 3.2 Regional Network: 13 of 16

14 These are the countries where NEXtCARE has contracted healthcare providers for direct billing outside the UAE: - GCC countries excluding KSA Procedure for GCC : For all insured groups based in the GCC, the table of benefits (coverage) and a soft copy of the medical card (one sample of each category) must be forwarded to the network department in advance to secure direct billing access at those GCC Network Providers. Healthcare providers in GCC have an advanced software system, the table of benefits for any insured group has to be uploaded in their system, or else the insured member will not be accepted on direct billing. - Lebanon Network: The member is advised to call NEXtCARE-Dubai or NEXtCARE Lebanon at to ensure direct billing access. - Egypt Network: The member is advised to call NEXtCARE-Egypt at to ensure direct billing access. - Jordan and Tunisia Network: For In-patient and Out-patient services. 3.3 International Network: This service is for In-Patient only. The service is provided through International Network Agreement. The member is advised to call NEXtCARE-Dubai to avail access on direct billing. 3.4 Visiting Doctors: Visiting doctors at NEXtCARE network of preferred providers do not follow the agreed upon charges with the healthcare provider, as they do not fall under the healthcare provider s management. The healthcare provider informs the insured member before giving the service, that the doctor is a visiting doctor. They also inform the member that any difference in charges, exceeding the agreed tariff, will have to be paid directly by him/her. This procedure applies to all visiting doctors locally and regionally. It is advisable to add a clause in the policy stating: Should the member choose to consult a visiting doctor at a network provider, the member shall be covered up to the agreed tariff as per the network provider charges. The difference shall be collected from the member. 3.5 Reimbursement Claims at Network Providers When a service is not covered on the members plan, but the provider has a negotiated rate with NEXtCARE, the beneficiary will be treated as a cash paying patient at Network providers. (Example: dental and maternity). 14 of 16

15 For eligible cases, whether on direct billing or reimbursement, the member must show their NEXtCARE card to obtain the network discount (If applicable). When the claim is processed, only the agreed upon tariff will be considered. If the card is not presented at the time the services are paid, the provider will charge fees at their discretion without considering the network tariffs. In such cases the member will be responsible for the difference between the network tariffs and the actual amount paid. To address this issue and avoid any inconvenience to the members, it is advisable to add a clause in the policy stating: NEXtCARE card must be shown at network providers on direct billing, as well as cash pay and reimbursement basis to facilitate all discounts possible. If the card is not shown, the member will be responsible to endure the cost difference. 3.6 Inclusion and nomination process Upon the inclusion of a provider in NEXtCARE Preferred Provider Network, certain criteria & performance expectations are looked into, as mentioned below: 1. Service Availability: Network providers that offer a full range of primary, secondary & tertiary services within the market area. 2. Service Accessibility: Network providers are distributed throughout the Market area to provide reasonable geographic (time & distance) access to insured patients. 3. Provider Quality: Network providers have met credentialing standards related to process and outcome measures of quality care. 4. Provider Cost Effectiveness: Fixed pricing arrangements which represent a competitive market price for the level of service provided and results in significant savings to clients Nomination request from Insurance companies: The nomination process and requirements are as mentioned below: 1. Official request stating the full name of the requested provider and all contact details/ location. 2. The name of the group requesting the provider (official request issued by the HR department of the client). Individual requests shall not be entertained. 3. The number of insured members in the group in addition to their network category. IMPORTANT NOTES: 1. The nomination process may take from 90 to 180 days. This is due to the following: 15 of 16

16 The high volume of requests received from various sources. Time taken to receive documents from provider. Evaluation of the documents provided and the price list. Negotiation with the provider. Site visit. Signing of contract. 2. Providers must meet credentialing requirements. 3. Providers must agree to contract provisions & procedures. 4. Nominations do not guarantee inclusion. Top Reasons for Denial of Application: 1 Unwillingness to participate in utilization review & cost-containment. 2 Pricing not benchmarked to peers. 3 Lack of experience with managed care. 4 Network capacity for specialty area not available. 5 Geographical capacity not available. 6 Invalid, questionable or incomplete licensure or credentialing information. 7 Recorded expulsion from other TPA network or insurance network. 8 Lack of fax, and computer infrastructure. 9 Failure to accept negotiated rates and limit maximum increases. 16 of 16