Coordination Committee
Discussion document
31 May 2007
Contents
• Review feedback from last meeting (DAMAN, Providers)
• Preparing for electronic data submission
• Status on uniform claims form and coding
• Proposal for outpatient flat fee payments
• Roadmap for inpatient DRG payments
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Selected feeback from DAMAN and public providers
DAMAN
Public
Providers
• Delayed claims
• At times inconsistent
• Incomplete/missing documentation (but improving)
• Many different formats and forms
• Excessive work up needed for outpatient claims
• No consolidation/summary of claim
• Manual billing (paper based and inefficient)
• Not customer (i.e., patient) friendly
• Shortage of staff
• DAMAN is doing the coding and introducing errors
• Incomplete price list without mechanism to update
2
Contents
• Review feedback from last meeting (DAMAN, Providers)
• Preparing for electronic data submission
• Status on uniform claims form and coding
• Proposal for outpatient flat fee payments
• Roadmap for inpatient DRG payments
3
Contents
• Review feedback from last meeting (DAMAN, Providers)
• Preparing for electronic data submission
• Status on uniform claims form and coding
• Proposal for outpatient flat fee payments
• Roadmap for inpatient DRG payments
4
We have talked to a number of people...
Daman (+EIA)
CEO
Clinical
Finance/
Operations
IT
Other
Dr. Michael Bitzer
Dr. Mohammed
Ezzat Agamy
Axel Tettenborn
Ramzi Rahal
Alisdair Burgess
Multiple (1)
Other Payors
Providers
Tawam
Michael Heindel
Mitchell Jesson
Saeed Al Kuwaiti
Ed Lembke
SKMC
Jay Cooper
Tim Nelson
Jay Cooper
Rejeanna Freij
Mafraq
Mujeeb Kandy
Abdulghani Al
Khemairi
Mutaz Ali
Rahba
Mujeeb Kandy
Corniche
David Saxton
Al Noor
Dr. Kassem Alom
AD-HSC
Saif Al Qubaisi
Coding Steering
committee
Ann Webster
HCT
Sameera Al Hashemi
Burhan Ahmed
Moazzem Khan
Ian Conroy
Selvakumar
Mohammed
Layla
Rose Sigurnjak
(Cerner)
Coding community
Pat Visovsky
Output of conversations is captured and made transparent on
http://healthstatistics.pbwiki.com
(1)Over 10
top insurance companies' senior managers during report management process, including ALICO, Arab Orient, Qatar, DNIC, Ahalia, Buhaira, Takaful, RAK, Sagar
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... and made signficant progress on our shared agenda
Activity
Principles
• Code an ICD9-CM diagnosis for every encounter
• Need a universal minimum data set to make a claim
Status
• Agreed(1)
• Agreed
– In the first instance, data set will include little more than an ICD-9
diagnosis, in order to get electronic claims working
– When electronic claims are working, jointly add clinical fields over
time in order to create – in effect – an electronic health record
Definitions
Implementation
(1)HAAD,
• Defined minimum Universal claims fields (draft)
• Make comments on wiki until 5 June [All]
• Done
• Finalise claims fields by 8 June [Dr. Finn/Dr. Philipp]
• Action needed
• Develop outpatient ‚cheat sheet‘
• Adapt HAAD reporting (content aligned with universal
claims; secure online submission process developed)
• Action needed
• Done
• Done
• Pilot electronic claims (Daman/Al Noor under way; DamanAl Mafraq agreed)
• Action needed
• Start claiming electronically with new claims form [Public
Hospital from 1 July 2007]
• Action needed
• Shift all all existing claims forms to be fully compatible with
universal claims form [All providers by end of year]
• Action needed
DAMAN, public and selected private providers
6
Contents
• Review feedback from last meeting (DAMAN, Providers)
• Preparing for electronic data submission
• Status on uniform claims form and coding
• Proposal for outpatient flat fee payments
• Roadmap for inpatient DRG payments
7
Addressing the Claims Gap
Claims gap
Barriers
Solution
• Public hospitals are filing many claims for services performed either
late or not at all
• This means that we are paying twice: once for insurance premiums
(which don’t get claimed by hospitals), and once for direct payments to
hospitals
• If this continues, people will fundamentally lose trust in health
insurance, which endangers the entire system reform agenda
• Public hospitals currently face two primary obstacles in claiming
adequately
– Claims process is complex (and not service-oriented)
– Collating information for making claims is difficult
• These issues are particularly stark for outpatients (>10x volume, <1/10
price of inpatients). The proposition is to
– radically simplify the claims process by introducing a flat fee for
outpatients with electronic billing
– increase clinical claims information once system is up and running
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Principles
Introduce a flat fee for outpatients
• Mandatory for all public hospitals
• Includes lab and diagnostics
• Excludes drugs
• Separate price for first and follow-up visits
• Steep discount for follow-up visit
• Follow-up to be robustly defined
• Claim needs to have an ICD-9 diagnosis
Risk management
• Calculate price to be revenue-neutral for average outpatient claim
• Pilot in a public hospital
• Review price automatically after three months
• Use price level as key lever to manage overall future claims ratio
• Conduct overall financial sensitivity analysis
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Specific proposal for outpatient flat fee
• Flat fee for outpatient attendance including all lab and
diagnosis („x-ray“)
• Prices:
AED
GP
Specialist
Consultant
First Attendance
150
210
240
Follow-Up
50
70
80
• Definition of GP, specialist and consultant: as in previous system
(by license)
• Definition of first visit: an attendance is a first attendance if the
patient has not been seen for this diagnosis within the last 90
calendar days by that provider
• Definition of follow-up: all non-first attendances after 7 days
following the first attendance
• Provider specific discounts at current levels (e.g., SKMC 200%)
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Contents
• Review feedback from last meeting (DAMAN, Providers)
• Preparing for electronic data submission
• Status on uniform claims form and coding
• Proposal for outpatient flat fee payments
• Roadmap for inpatient DRG payments
11
Suggested Roadmap for DRGs
Coding
Payment
• Agree universal use ICD9-CM for diagnoses and procedures
• Restrict use of the term ‘DRG’ to true DRGs (not prices)
• Agree universal use of 3M-Grouper
• Change billing of inpatients to DRG only by 1 October 2007
–All activity from 1 Jan 2007 to be claimed as DRGs
• Agree use of pre-set 3M-Grouper weights
• Define base rate for each provider
• Define activity-based costing programme to revise weights
and base rate
–Conduct pilot programme in Tawam (Saeed Al Kuwaiti)
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