July 6th 2011 - IR-DRG Panel Meeting Minutes
Wednesday July 6th 2011 9:00 AM-12:00 PM – 3rd Floor Meeting Room, HAAD
Time and location:
Panel Members :
Dr. Finn Goldner (Chairman), Linda Vandijk(DAMAN), Antoine El Achkar (Lifeline Hospital), Catharine Ann Downing (SEHA) on behalf
of Wayne Keller(SEHA),
Absenteeism:
Michelea Peech (CCSC), Wayne Keller(SEHA), Mohammed Mazhar Hamadeh(Al Ain Ahalia Insurance),
Non-Panel Members
Mahmoud R.I AbuRaddaha (HAAD)
Other Attendees
Mazen Malhis (Al-Noor Hospital), Dr. M. Ezzat Agamy (Lifeline Hospital), Anandan Saravanan (NAS TPA) , Malda Bashi (AccuMed).
A - General Items
ID
Agenda Item
A.
Meeting Kick-off and opening
statement.
Adviso
r
FG
Comments



B.
Overall market feedback
LV



EA


Comments about individual DRG weights, weights for the lower severity and DRG mapping are still being
received by the HSF division, however -through observation- the providers’ community seems more
comfortable with the new weights.
There is increase interest in the DRGs by the private healthcare entities: providers, IC and TPAs, in
preparation for the inclusion of the DRG prospective payment system as the method of billing and
reimbursement for the inpatient encountered in the newly signed / renewed contracts.
The Health Authority has received requests for delay of the implementation. The Health Authority
remains firm on the implementation on the set date of Jan 1st 2012.
Submission is smoother compared to the prior period.
Claims with “Denied Services” is an issue which needs to be quickly addressed as it is causing for some
claims to remain unsettled.
From payment perspective and subsequent to the weight update, Damans books suggests a higher
overall payment, however some concern about the appropriateness of the weights for the DRGs with
lower severity.
Earlier in the year there was less clarity on the billing and reimbursement rules in regard to DRG
(example secondary diagnosis) which has cause concerns in the providers community, most of which
have been addressed and resolved but some requires further clarification.
New weights are better that what was before but not optimal, i.e. doesn’t cover the cost for some of
the DRGs especially for IP with implants.
CD




AS
MM
As we have more clarity on the DRG update mechanism, SEHA is now capturing more data on the claim
which will help in better DRG weight calculation.
Agrees with Daman that the claims with “Denied Services “is an issue and causing for some claims to
remain unsettled.
Denial of Secondary Diagnosis seems to continue, SEHA will review its records and present its
complaints, if any, to the concerned parties.
There is no clear mechanism on how the system will adapt to the increase of cost of implants which is
(estimated by 20%.

From TPA perspective, NAS is interested in contracting using DRG prospective payment system and is
taking the steps to include the DRGs in the new SPCs for calendar year 2012.

From Al-Noor perspective several DRGs with lower severity have been unfavorably affected by the new
weights, hence request that the weights gets reviewed again to fairly reimburse for the services
rendered for patients with lower severity.
B - Agenda Items
ID
23
Date
Adviso
r
06-Jul-11 HAAD
Proposal/Comment/Question


24
06-Jul-11 HAAD
Review and approval of CCSC definition
of readmission.
Discussion of the mechanics of utilizing
the definitions in implementation of
the 2% augmentation on the base rate
for Basic product.
Continuity of Pharmaceutical Care to
discharged patients
Proposal
hospitals conduct pre-discharge
medication review and dispense:
 The lesser of; remainder of treatment
course of prescribed medication,
including antibiotics, or 7 days supply.
Action/Decision
Action
Owner
The panel discussed the definition of readmission
approval of CCSC, and has identified the following
areas of concerns,
 The definition is based on ICD-9 category instead
HAAD /
of the MDC.
 The definition is some aspects conflicts with the Panelists
standard definition of readmission: CCSC is ICD-9
based while the standard is DRG based.
 Some of the excluded readmissions scenarios are
difficult to statistically measure (e.g
readmission for medical conditions that were
not medically possible to be performed in the
same admission).
 The definition doesn’t account for the
readmission due to complications of the initial
admission.
Decision /Panel Voting:
 Request HAAD strategy and CCSC to provide the
statistical framework for implementation of the 2%
augmentation on the base rate for Basic product using
the provided definition.
Decision:
Daman has suggested that the supply period be for 14
days and not 7.
 Healthcare providers suggested that the cost of
discharge medication to not be part of the inpatient
encounter as it will put additional financial burden on
the service providers.

Panel Voting
 FG voted yes.
HAAD
Material
Readmission
Definition
Discharge Medication


25
26
06-Jul-11 HAAD
06-Jul-11 HAAD

No supply of medication for established
Chronic Condition, or refill of
medicine, that were Present on
Admission. Unless, the medical
condition was designated as the
encounter principle diagnosis, in which
case remainder of treatment course or
7 days supply, whichever is lesser, shall
be dispensed.
Supply of medications is aimed to
ensure that patients are supplied with
sufficient quantity that sustains
continuity of pharmaceutical care after
discharge. Hence, shall be covered
under the insurance inpatient benefits
scheme, and be reimbursed to the
service provider, using the rules in
effect, as a part of the inpatient
encounters.
Evaluation of the need for 2nd IR-DRG
weights update in Q4
DRG Panel to clarify the rules around
payment of DRG claims when Payer
calculates a different DRG than reported by
the Provider in a claim.
 Relates to DRG panel issue id 21 & 22.
 And DSP decision 151



LV voted yes.
CD voted no.
AA voted no.
Panel Chairman used the casting vote, proposal hence was
accepted.

Decision /Panel Voting:
The panel members have voted for weight updated
which should,
 Account for the suggestions made earlier by the
panelist in response to the first update.
 Account for the increase in the implant cost
increase.
 Be presented to the panel in the next Panel
meeting and before being published for
consultation.
 Follow the implementation scheduled set by the
claims and adjudication rules (published in
October 2011 with effective date Jan 1st 2012.
Decision /Panel Voting:
 As this item was not present in the original
agenda, the panel agreed on have it discussed
on a subsequent meeting or through e-mail
voting
HAAD
March 24, 2011 - IR-DRG Panel Meeting Minutes
Time and location:
Thursday, March 24, 2011 9:00 AM-12:00 PM – 3rd Floor Meeting Room, HAAD
Panel Members :
Dr. Finn Goldner (Chairman), Linda Vandijk(DAMAN), Wayne Keller(SEHA), Mohammed Mazhar Hamadeh(Al Ain Ahalia Insurance),
And, Michelea Peech (CCSC).
Antoine El Achkar (Life line Hospital).
Absenteeism:
Non-Panel Members
Mahmoud R.I AbuRaddaha (HAAD), Dr. Shereefa Fatema Afreen(HAAD)
Other Attendees
Lina Jichi (HAAD), James Basil Bardopoulos(HAAD), Catharine Ann Downing (SEHA), Ann Webster (SEHA & CCSC),
A - General Items
ID
A.
Agenda Item
Meeting Kick-off and opening
statement.
Advisor
Dr. Finn
Comments
 Good efforts have been made in the implementation of the DRG for Thiqa (SEHA) and Basic
Product (All Providers); Claims are now flowing, as well are the payments.
 For the Enhanced product, the market seems to remain observant of the Thiqa and Basic,
nonetheless needs to take more proactive steps toward the understanding of impact and values of
the DRG system.
 Issues reported in the previous meeting have been addressed, today’s meeting will provide
resolution for some however few other are still to be resolved.
B.
Overall market feedback
Michelea


Feedback received is generally positive.
Majority of the Mapping issues have now been resolved, however minor issues are still work-inprogress.
Linda V.

The general observation is that the providers are cooperative and are actively participating in the
success of the implementation of the DRG Prospective Payment System for the Basic Product (and
SEHA for Thiqa).
Workshops have been conducted to educate the market about the DRG, participation and
outcomes were positive. Daman is currently dealing only dealing with sporadic and individual
questions and queries, and haven’t decided yet to conduct any further group workshops.
Grouping and Mapping review still required, Daman will continue to coordinate with Michelea on
any reported or encountered Mapping issues.




Wayne K.

Providers are not active in providing feedback on the implementation, however the forthcoming
weigh update might change that.

Provider Manuals are not currently covering the IR-DRG related operational procedures and
protocols.
TPAs are interested in contracting with SEHA, however holding on converting to the DRG
Prospective Payment System. Market Educational Workshops might be able to change that.
DRG claims processing started as tough however progress is being achieved.


Moh’d H.
For its Enhanced Products, Daman is still evaluating the financial impact of the transition to the
DRG Prospective Payment System.
Stats wise;
o Daman has received ~ 22,000 inpatient Claims. Out of which ~80 have hit the outlier. Of
which 20% to 30% are with unsupported secondary diagnosis. Audits have confirmed wrong
coding in these cases.
o 25% rejection rate. 15-30% of the rejections were found to be appropriate through the desk
audit.
o Daman has also noted pushing out of services to different payment schemes.




Dr. Finn
No major issues have been reported by the Insurance Companies, as majority remains observant
of the current market dynamics.
Majority of the Insurance Companies utilized the TPA services in its Networking, Contracting and
Claims administration functions; hence it will be beneficial to have TPAs as none-voting
participants in the DRG Panel.
Insurance Companies Stats suggests high “Fraud and Abuse” rate: raising from 10-15% to ranges
between 30-40% of the billed amounts. Implementation of DRG system will shift the risk to the
providers, promote efficiency and clear the IC worries about any potential provider abuse.
Feedback received by HAAD can be summarized by the following:
o Case Complexity is underpaid.
o DRG’s weights are not inline with the market practice.
B - Agenda Items
ID
Date
Adviso
r
Proposal/Comment/Question
Action/Decision
Action
Owner
Material
18
24-Mar-11
Lina J
Proposal for IR-DRG weights update.
Decision /Panel Voting:
There was consensus on the presented methodology
and the need to update the weights.






19
24-Mar-11
HAAD/
Implementation of the 2% augmentation
Actions
Panelist provided immediate feedback and
recommendations, that shall be considered by HAAD
in the subsequent updates:
o Daman: Future updates should exclude not covered
services, duplicate charges, and billing errors.
o SEHA: Physician charges should be reflected in the
overall cost, which shall be achieved by the proper
and exhaustive coding by the service providers.
o Daman: Calculations based on the current Basic
Product Pricelist as the best proxy cost is fine,
however suggested using the mode or median
rather than the weighted avg for non-priced service
and HCPCS codes.
The calculation methodology and new weights are
posted in HAAD website (Data Dictionary /
Governance / DRG Advisory Panel) for public review
and consultation.
The consultation period expires on 8th Apr.
Public comments should be channeled through the
panelists.
In case of disagreement with particular aspect of the
overall methodology or specific DRG weight, for a
change to be considered by HAAD: a) there should be
a consensus on the disagreement and b) a proposal
for an alternative methodology that is supported by
the required statistical analysis and logic.
There will be regular upgrades to the IR-DRG
weights. HAAD will provide the framework regarding
the inclusion of the updates in the contractual
structure set by the Standard Provider Contract.
Decision /Panel Voting:
11-03-12 Weight
Updates.pptx
HAAD /
Panelists
Daman
20
24-Mar-11
Wayne
on the base rate for Basic product in
case of readmissions.
Proposal:
 Rules set by DSP (currently in voting)
are aimed to set the clear rules in
regard to the “Transfer” e-claims
submission. Subsequent to the DSP
decisions, CCSC will be requested to
provide the lexical (words) definition
of transfer, to remove ambiguity
between various types of transfer
(i.e. to acute care, post-acute care
and long-term care etc)
 Charging CCSC with setting a
definition of readmission.
 Charging Daman with Augmentation
mechanics and implementation
timetable using the CCSC readmission definition, and the rules
set in the DRG Standard.
SEHA requested revisit of items 6 &7 of
Nov 25th Panel meeting concerning:
 Cochlear and other high cost
Implants.
 High cost drugs and drugs costing
more than 6000 AED.
 Implants, costing more than 3,000
AED
Proposal:
 Review of the cost of high cost
drugs and supplies in lights of the
suggested IR-DRG updates.


Accepted the Transfer definition set by DSP.
Consensus on the proposed action plan for the
proposal for the Implementation the augmentation.
Actions

Submit a request to CCSC to provide lexical (words)
definition of Transfer and Re-admissions.
HAAD/
CCSC

Charging Daman with Augmentation mechanics and
implementation timetable, subsequent to the CCSC
definition finalization.
HAAD/
DAMAN

Expensive Drugs and Implants (HCPCs) are accounted
for in the new IR-DRGs weights update.
HAAD will define and publish Specialized and NonMarket DRGs, which will protect the providers
offering highly specialized and infrequently offered
services.

HAAD
Cochlear Implants
Medical # removed.xlsx
High cost drug more
than 6000 AED and claimed amount 20
Implants, etc more
than 3,000 AED.XLSX
Top 100 high cost
drugs oct 2010.xlsx
21
24-Mar-11
Wayne
SEHA’s claims are denied by Daman due
to:
i. Differences in grouping methods;
where Daman groups by putting in only
the billable services whilst SEHA puts
in all the items, services and
secondary/tertiary diagnosis.
ii. Omission of certain activity data that
Daman determines should have been
included. For instance, Daman may
determine that there is no evidence
that co-morbidity has been treated
during
a
hospital
stay
(e.g.
hypertensive medication given to a
patient with hypertension); as such,
Daman will exclude this diagnosis when
grouping.
iii. Denials do not include the changed IRDRG, or any payment for the changed
IR-DRG’s. SEHA proposed that this be
changed as hospitals are now unable to
deal with resubmissions as they have
no idea on how the IR-DRGs have been
grouped.
Proposal,
In light of the diagnosis
approved by CCSC on March 1:
definition
 Secondary diagnosis (es) can be
excluded if it relates to an earlier
episode that has no bearing on the
current hospital stay.
 Secondary diagnosis (es) if relates to
uncovered condition but has bearing on
the current hospital stay shall not be

Decision /Panel Voting:
Proposal was discussed with modifications. The new
proposal the panel voted on is as follows:
o Secondary diagnosis coding shall follow CCSC
published rules. Accordingly providers shall refrain
from coding a secondary diagnosis (es) that refer to
an earlier episode and have no bearing on the
current hospital stay.
o Diagnosis (es) not supported by coded services shall
not be excluded by the Insurance Companies during
adjudication as such diagnosis(es) might have
influence on the length of hospital stay, or
increased nursing care and/or monitoring. However,
can be flagged for audit, and be subject to recovery
if confirmed to be wrongly coded by the medical
record audit.
o Confirmed Coding errors shall be reported to CCSC
for review and potential cancellation of audit
certificate for the frequent violators.
o Secondary diagnosis(es) if relates to uncovered
condition but has bearing on the current hospital
stay shall not be excluded from the DRG payment.

The revised proposal was approved using the
“Majority Rule”:
o 3 votes with; Wayne and Dr. Finn, Michelea.
o 2 votes against: Linda and Moh’d.
Payers
and
Providers
Final Definition for
Diagnosis.doc
excluded from the DRG payment.
 DSP will be requested to provide the
technical solution that supports the
above resolution.
22
24-Mar-11
HAAD
Through various requests HAAD was asked
to provide further clarifications on the
calculation of DRG Outliers;




Billing Methodology (Fee for service,
Perdiem …etc).
Pricelist to use.
Services that can be excluded from the
DRG payment.
Proposal:

HAAD will provide through formal
communication clarification in regard
to the Billing Methodology and
Pricelist, as those items were already
pre-defined in the DRG standard:
o Billing Methodology: Fee
for Service.
o Cost = Mandatory Tariff
prices regardless of the product.
 Services that can be excluded from the
DRG / DRG outlier payment shall be
limited to:
o Billing Errors and duplicate charges,
using simple and complex edits as
defined in HAAD adjudication standard.
o “Medically impossible” charges:
services that couldn’t have been
provided due to:
 Patient gender restriction.
 Patient age restriction.
 Patient previous medical history.
o Material not-covered item under the

Decision /Panel Voting:
Proposal was approved by the Panel members with
the following final wording:
Services that can be excluded from the DRG / DRG
outlier payment shall be limited to:
o
Billing Errors and duplicate charges, using
simple and complex edits as defined in
HAAD adjudication standard.
o “Medically impossible” charges: services
that couldn’t have been provided due to:
 Patient gender restriction.
 Patient age restriction.
 Patient previous medical history.
o Not-covered item under the insurance
plan.
Rules are applicable to DRG and DRG outlier
calculation.
Actions:


HAAD
HAAD
HAAD will provide through formal communication
clarification in regard :
o Billing Methodology: Fee for Service.
o Cost = Mandatory Tariff prices regardless of the
product.
o Charges that can be excluded from the DRG / DRG
outlier payment.
DSP will be requested to provide the technical
solution that supports the above resolution.
HAAD
insurance plan.

DSP will be requested to provide the
technical solution that supports the
above resolution.
25 November, 2010 IR-DRG Panel Meeting
Name of Organization: Health Authority of Abu Dhabi
Time and location: 9.00am to 11.30 a.m - 25 November, 2010- 2nd Floor Meeting Room, HAAD
Panel Members : Dr. Finn Goldner (Chairman), Linda Vandijk(DAMAN), Wayne Keller(SEHA), Antoine El Achkar (Life line Hospital),
Mohammed Mazhar Hamadeh(Al Ain Ahalia Insurance), and Michelea Peech (CCSC)
Others
Mahmoud R.I AbuRaddaha (HAAD), Dr. Shereefa Fatema Afreen(HAAD),
Guests
Cathryn Downing (SEHA) , Mariano Gonzalez (Al Noor Hospital)
Apologies
No apologies.
Absent
No absenteeism
General Items
Item
ID
1.
Agenda Item
Advisor
 Meeting Kick-off and
opening statement.
 Panel duties and role.
 General expectations
from Panel Members.
Dr. Finn
Goldner
Action Decision
The Panel shall assemble each quarter and shall be considered a
quorum if three Panel members including the Chairman with at
least one payer representative and one provider representative
attend. Next meeting date will be formally communicated to the
Panel Members and Public on HAAD website 15 days prior to the
meeting.
Action
Owner
HAAD
Material
Industry representatives shall collect industry feedback and
proposals of their sector to the panel. However proposals can be
submitted either through panel members or directly to HAAD:
 Contacts details of panel members shall be published at HAAD
website (see Item ID 2).
 To HAAD through Ms. Huwaida Obaid at hobaid@haad.ae.
Panel
members
All proposals are to be specific, and should be supported with price
cost analysis and relevant supportive materials and evidence, and
be made in writing to the Chairman of the Panel.
Minutes of the panel meeting will include proposals, discussions,
actions and decisions of the panel, will be captured by HAAD and
published with public access in HAAD website www.haad.ae /Data
Dictionary/ Governance / DRG Advisory Panel. Also;
 Direct Communication to the panel members prompting to
review and verify the minutes will be uploaded to HAAD
website.
 HAAD shall create an internet push-system which shall send
intimations to other registered members. Further updates
regarding this system is to be provided to the public in Q1 of
2011.
2.
Introduction of Panelists.
Panel
members
1. Dr. Finn Goldner (Chairman) –Director
Health System Financing
Health Authority Abu Dhabi
P.O. 5674
Abu Dhabi, UAE
Tel.+971 41 93 563
E-mail: fgoldner@haad.ae
2. Linda VanDijk(DAMAN)
Manager Medical Strategy and Development Department
National Health Insurance Company – Daman
P.O. Box 128888
Abu Dhabi, UAE
HAAD
Dir. Tel: +971 2 614 5658 | Mobile: +971 56 614 6254 | Fax:
+971 2 614 9773
E-mail: linda.vandijk@damanhealth.ae| Website:
www.damanhealth.ae
3. Wayne P.Keller(SEHA)
Director – Head Revenue Cycle Management
SEHA
Tel.Mobile 050 533 1585
Office 02 410 2788
E-mail: wkeller@seha.ae
4. Antoine El Achkar (Life Line Hosital representing Private
Providers),
5. Mohammed Mazhar Hamadeh(Al Ain Ahalia- Representing
Payers,
6. Michelea Peech (CCSC)
Clinical Coding Consultant
Chair, Clinical Coding Steering Committee
Health Authority of Abu Dhabi
Cell +971 50 1414172
 General impression
about IR-DRG
experience so far.
Panel
members
E-mail: mdpeech@hotmail.com
 Overall, panel members’ impression about the IR-DRG
implementation to-date was positive. However, there was a general
agreement on the need to keep the figure on the pulse and deal with
the minor issues that might be encountered in the coming phases as
they arise.
 Other topics discussed,
 Coding issues.
 Operational issues.
 The need for change of practices.
 Efficiency requirements.
Issue
ID
1
Date
/Agenda
Item
9-Nov-10
Advisor
Proposal/Comment/Question
Action/Decision
Action
Owner
M. Mazhar
 The Payer’s Trade license does not
allow them to act as collection
agent on behalf of any third Party
 There are procedural and admin
difficulties in collecting these fines
which include, but are not limited
to :
 The panel did not consider the
reported issue a DRG related topic.
However, as it is a subject of public
concern, Al Ain Ahalia was advised to
contact the Inspection &
Enforcements Section at the Health
Systems Financing for further review
of this matter.
M. Mazhar
 HAAD team agreed.
 Minutes of the panel meeting will
include: proposals, discussions,
actions and decisions of the panel,
will be captured by HAAD and
published with public access at
HAAD website www.haad.ae in Data
Dictionary.
 Also
 Direct Communication to the
panel members prompting to
review and verify the minutes
HAAD
i) Local transfer of an employee
within Abu Dhabi
ii) Local transfer of an employee
from other Emirates to Abu Dhabi
with no previous medical
insurance
2
9-Nov-10
M. Mazhar
iii) Person arrives on visit Visa to
be converted to employment visa.
No previous insurance.
HAAD notifications, including
circulars and letters, regulations,
explanations, amendments etc. must
be communicated directly to
stakeholders. The market should
not be expected to regularly followup at the HAAD Web-site.
Material

3
9-Nov-10
M. Mazhar
4
9-Nov-10
M. Mazhar
HAAD and other Stakeholders
(Payers Providers and TPAs) must
have a closer relationship as
partners to ensure smooth
operations instead of HAAD
imposing a constant threat of fines
and penalties.
Can UAE Nationals from outside Abu
Dhabi Emirate be insured under
Medical plans other than Thiqa?
will be uploaded to HAAD
website.
HAAD shall create an internet
push-system which shall send
intimations to other registered
members. Further updates
regarding this system is to be
provided to the public in Q1 of
2011.
 Topic relates to issue ID "1", hence
same Action/Decision applies.
M. Mazhar
All parties
 With reference to the Health
involved
Insurance Circular 26 and as
stipulated under Law 2007/83 and
Law 2005/23, UAE Nationals are
strictly forbidden to possess “Double
Insurance” policies. However,
confirmed that THIQA is not a
mandatory product, any national has
the option to obtain health insurance
other than THIQA through their
employers. In addition, HAAD has
just published the framework for
THIQA Top-Up products, which
complement the current THIQA
benefits and can be bought from the
private sector. Further information in
this regard can be obtained from HSF
/“Authorization” section.
5
9-Nov-10
M. Mazhar
6
9-Nov-10
Wayne P. Keller
Antoine El Achkar
7
11-Nov-10
Wayne P. Keller
Can UAE Nationals, who are part of a
Group Scheme be insured under
Medical Plans other than Thiqa (they
may wish to receive additional
benefits)
Providers are of the opinion that a
few IR-DRGs do not cover-up
treatment costs including costs for
expensive drugs and durable
medical supplies.
 Topic relates to issue ID "4", hence
same Action/Decision applies.
All parties
involved
 The IR-DRGs reimbursement is based
on average case cost, rather than
separate individual items.
 Each DRG represents the average
resources needed to treat patients
grouped to that DRG. (weights are
calculated by 3M, on international
utilization of average hospital
resources)
 HAAD recognizes the need to develop
local weights to better align levels of
reimbursement to reflect our young
population (in comparison to high
elderly population in western
countries) and our national
epidemiological factors e.g. higher
percentage of patients with
childhood diabetes.
 HAAD should calculate cost
weights for cases in future as
Abu Dhabi specific cost data
become available.
 Assess Abu Dhabi weights
versus IR-DRG weights
 Reweighting could occur on an
annual basis or less regularly
HAAD &
All parties
involved
SEHA has submitted a list of items
which are presented for
consideration as potential pass
Price for individual items cannot be
dissociated from the total IR-DRG cost.
However it is part of HAAD plans to
HAAD &
All parties
involved
through items over the Basic IR-DRG
rate. These items include:
 High Cost Drug (more than AED
600 claimed in 2009.
 Cochlear Implants and others
 Top 100 high cost Medications
8
14-Nov-10
Linda Vandijk
What is the scope of the Panel and
what are its given responsibilities,
power of decision? How does the
panel relate to other bodies such as
DSP and CCSC, e.g.. Which panel will
supersede in case of converse
decisions?
9
14-Nov-10
Linda Vandijk
What will be the timelines and
process for (annual) update of the
IR- DRG set of relative weights and,
factor in all the cost factors while
localizing the IR-DRG weights as
explained in issue ID “6”
Action/Decision.
In case of Outliers, please refer to the
DRG Standard available at the HAAD
website www.haad.ae under Policies
and Circulars.
 Please refer back to DRG standard
Clause 7.2. Also see Action/Decision
of item no. 1.
 The panel is advisory in nature,
and is expected to act as the
voice of the market in matters
that are in concern to IR-DRGs.
 The panel responsibilities
revolve around reviewing
operational issues, concerns
and problems arising from the
DRG system & implementation.
 The final decision for revisions
and/or updates to payment
rules remain the sole
responsibility of HAAD. In
addition the rates for the Basic
Product are solely governed by
HAAD. Nonetheless, the
advisory panel will act as an
active participant in the review
and feedback on any proposed
changes / updates before they
come into effect.
 Please refer back to issue ID “6”
Action/Decision.
HAAD
HAAD
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Linda Vandijk
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14-Nov-10
Linda Vandijk
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Linda Vandijk
if allowed, what will be the criteria
for adjusting individual weights to
ensure the internal relativity? What
will be expected from the Panel in
this process?
How does HAAD intend to
implement the 2% augmentation on
the base rate for Basic product in
case of readmission rates in the best
quartile?
How will the Newborns exceeding
their mothers In-Patient stay be
covered under the IR-DRGs
payment? When will HAAD confirm
the decisions to payers and
providers including:
 The 30 day coverage of Newborns
for Basic product?
 Inclusion of Outpatient and
Emergency services delivered to
the patient less than 48 hours
prior to his/her In-Patient
admission for the DRG in the DRG
claim?
Missing encounter start and end
time. Many providers are populating
the compulsory fields encounter
start and end time as 0:00, whereas
the times are required to
discriminate between an inpatient
stay and a day case. Daman will pay
as per HAAD standard; FFS for day
case and DRGs for inpatient stays.
- Absence of encounter end type
 Advisory panel will act as an active
participant in the review and
feedback on any proposed changes
and/or updates to the weights before
they come into effect.
 To be discussed in next meeting.
 Both topics are in review, and
clarification is scheduled to be
published in the month of December.
HAAD
Newborn Health
Care Payment Calculation.p
Note; following related actions were
taken after the meeting:

Newborn Health Care Payment
Calculation letter was published
on 14/12/2010. (See PDF
attachment for reference).
 Encounter start and end time is
required as indicated in the Data
Standard. Hence Payers must
exercise their right to audit providers
who constantly submit claims with
encounter start and end as 0:00.
 Absence of encounter end type
‘transfer’ in transfer cases, is
considered incorrect coding, and
must be avoided by service
providers.
Providers,
Payers &
CCSC
‘transfer’ in transfer cases. We have
come across claims that are billed as
DRGs whilst evidence in the e.g. The
patient file or documentation ion
authorization request by receiving
hospital. Daman will pay as per
HAAD standard; per diem without
procedures for the transfer provider.
If the amount claimed by a provider
is higher than the price set for the
billed 7 digit DRG code (thus
mismatch of DRG code and DRG
price), Daman will pay not more
than the price set by HAAD for the
billed 7 digit DRG code, if correctly
billed.
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Linda Vandijk
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Linda Vandijk
What should be a Payer’s stand in
cases where Providers bill either no
procedures or bill only those which
impact the DRG grouping?
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Linda Vandijk
What are HAAD’s views on cases
where an Inpatient DRG is billed
without a major procedure, and is
then followed by a quick
readmission for the same DRG,
where the major procedure is
NB: CCSC will create a definition for
“Transferred Cases" and publish it on
the HAAD website in due course, to
provide further clarity in the coding
requirement for transferred cases.
 HAAD agrees.
 For the Basic Product the prices are
set by HAAD and should be paid as
set. For Enhanced and Thiqa, prices
are negotiated between the Payer
and Provider, and prevails for
reimbursement of services
performed during the contract
period.
 As per HAAD’s Standards, all
procedures, services and
consumables must be included in the
encounter, regardless of it impacts
on the DRG reimbursement.
Encounter with missing treatment
details shall be considered
incomplete. Accordingly, Payers can
exercise their right to audit providers
constantly flagged for such billing
errors.
Payers and
Providers
 If true as stated, this will be
considered Case-Splitting which is
not allowed as per the current
regulations.
 Payers must adjudicate such claims
per the Claims Adjudication
Payers and
Providers
Payers and
Providers
carried out and billed?

16
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14-Nov-10
Linda Vandijk
Linda Vandijk
There seems to be a major increase
in secondary diagnosis in claims and
often a payer cannot find proof of
increased resource consumption.
Daman is preparing adjudication
guidelines for:
 Cases that require clear evidence
of CPTs, drugs, HCPS etc on the bill
and
 Cases that require further patient
file investigation by our field
medical officers.
Per the DRG Standard, providers are
not required to update their
authorizations. To date, Daman has
processed many requests for DRG
changes, but we will change process
to accommodate such requests in
special cases only (to be
communicated shortly)



Standard. Please refer back to
HAAD’s Website www.haad.ae /
Policies and procedures / Claims
Adjudication Standard.
Payers can exercise their right to
audit providers constantly flagged
for such billing errors.
Coding must be complete; hence
secondary diagnosis, even if not
supported by a procedure, service or
resource consumption in the
encounter, must be coded.
In case of proven intentional miss
coding (abuse), the payer must
report the provider to HAAD.
Data Standards Panel should be
contacted to decide which denial
code to use.
 As per the DRG Standard, providers
are not required to update their
authorizations. Hence payers must
take the necessary internal actions to
comply with the standard.
Payers
Payers