A Health Industry solution for Online Hospital and Medical Claiming August 2008 A Health Industry solution for Online Hospital and Medical Claiming Lynda Smith BUPA Australia

Industry Issues The information flow and the provision of eligibility and claiming data for in-patient episodes of care is complex, disjointed, labour intensive and expensive for all involved parties. Simplified Billing - 40% of claims result in rejections through simple data errors (3.8 million) - claiming inefficiencies resulting in manual intervention Informed Financial Consent - low % of members being informed of gaps

A health sector partnership ECLIPSE is a partnership between a broad range of health industry, interest groups: All Health Funds Software vendors (hospital and medical) Providers (AMA) Practice Managers (AAPM) Public and Private Hospitals Medicare Australia Department of Health and Ageing, and Department of Veteran Affairs

Common Goal Improve the Consumers claiming experience To streamline the claiming process To reduce paperwork and manual processes Increase efficiencies Reduce costs and save time Provide benefits for ALL stakeholders involved in the claiming process

What is ECLIPSE? Electronic Claims Lodgement and Information Processing Service Environment ECLIPSE is an Internet based on-line claiming solution that allows for the submission of claims to either Medicare, Private Health Funds or DVA directly from a providers or hospital’s desktop. All transactions are secured by PKI encryption.

HUB Health Fund Path/Rad GP Medicare Specialist Hospital DVA Consider a typical patients episode of care: [click] The patient has an illness, and visits their GP [click] The GP may be unsure of the condition, and orders some diagnostic tests [click] Upon receipt of the results, the GP refers the patient to a Specialist [click] The Specialist determines that surgery is required, and books the patient into the hospital, where the surgery is performed. In some cases, in-patient consultations may be appropriate, as well as additional diagnostic requests. So where does the ECLISPE HUB fit in? [click] The ECLIPSE Hub connects the entire Health Sector - facilitating the passage of claims and associated information from point-to-point over the internet. Re-visiting our example, post-surgery several accounts are raised: [click] The GP raises an out-patient consultation with Medicare, If the patient has Private Health Insurance and they also visited the patient whilst they were admitted to the hospital, they can raise an in-patient claim with both Medicare and the Patient’s Health Fund, [click] The out-patient Pathology tests, may be claimed from Medicare, and if further tests were ordered whilst the patient was admitted, those tests may be claimable again with both Medicare and the Patient’s Health Fund, [click] The Specialist too can raise in-patient and out-patient services with Medicare and/or the Health Fund, [click] And lastly, the Hospital can raise their account with the Patient’s Health Fund. [click] Under the ECLIPSE system, all transactions are secured using PKI encryption for everyone’s piece of mind. DVA

Functionality Australian Childhood Immunisation Register Overseas Claims DVA Medical Claiming Electronic Remittance Patient Verification Medicare Patient Verification Fund Online Eligibility Checking Bulk bill (DBS) Schemes Claims Online Patient Verification Hospital Claims Agreement Claims Patient Claims (PCI, PCS & IMC)

In-Patient Medical Claims Simplified Billing Claims submission of in-patient medical claims (no and known gap) to both Medicare and the Health Fund in one transaction payments made directly into the providers bank account via EFT Patient Claims 75% from Medicare, 25% from Health Funds Two Way claims Patients will receive 2 payments, 1 from Medicare and 1 from the Fund.

Other Claiming Functions Overseas Claims submission of both In-patient and Out-patient medical claims for persons who have no Medicare entitlements and special Health Fund coverage. Hospital Claims submission of both public and private hospital accommodation claims

Patient Eligibility Online Eligibility Checks Hospitals can check the eligibility of patients for Health Fund benefits prior to admission Medical providers can check the eligibility of patients for both Medicare and Health Fund benefits, Will assist practices to obtain Informed Financial Consent (IFC) from their patients Online Patient Verification Validity of Patient information with Medicare and/or the Health Fund

Other Features Electronic Remittance (Hospital and Medical) Matches EFT payments in the providers bank account against any ECLIPSE, simplified billing or hospital claim processed. Advanced Reporting Check the status of any claims submitted at any point in the flow Puts the provider in control of the process Report repository

In-Hospital Medical Claim (IMC) Paid or Unpaid Accounts (depends on claim type) for - 1 Patient 1 Billing Agent (if applicable) 1 Fund Payee ID (if applicable) 1 Principal Provider Multiple Servicing Providers (Limited to 1 Principal Provider and multiple Assisting Providers) Multiple Services Multiple Dates of Service

ECLIPSE: Simplified Billing Claiming Process (3) Enrolment Check (9) Claim Assessed & Payment Parked (15) Payment Processed Shows Flow for Claim under Gap Cover Arrangement HUB Medicare Health Fund Practice Management System Medical Provider (16) Existing Medicare Payment Engine sends Payment to Health Fund (14) Advice to Pay passed to Medicare (8) Claim Sent to Medicare (2) Enrolment Check (4) Enrolment Check Result (10) Claim Assessment Result sent to Hub (5) Membership Check (18) Payment sent by existing Health Fund System (7) Membership Check Result (1) Claim Submitted (13) HF Assessment & Advice to Pay sent to Hub (11) Claim & MC Assessment Result sent to Health Fund (6) Membership Check (12) Health Fund Processes Claim (17) Health Fund Pays Claim

ECLIPSE Development Arrangements Medicare Australia Government Budget Funding ($56.5M) till 2008 Software Vendors Responsibility Health Funds Responsibility Hospital PAS Or PMS Health Fund System HUB Client Adapter Server Adapter

Public Key Infrastructure (PKI) Security Why is ECLIPSE using PKI? Our concern was to ensure that offering our services online would in no way diminish the security, confidentiality and trust that our customers currently have. Medicare Australia was already working with software providers to ensure all electronic business applications available to Australian health professionals were incorporating PKI.

Public Key Infrastructure (PKI) Security The Health eSignature Authority Pty Ltd (HeSA) was established under Corporations Act 2001 as an independent subsidiary of the HIC. It is the body responsible for PKI registrations in the health sector. http://www.hesa.com.au/

Public Key Infrastructure (PKI) Security PKI enables users to know: who sent the message (authentication) the message content has not been altered in any way between sending and receiving (integrity) the sender cannot at some later stage dispute they created and sent the message (non-repudiation), and that only the person the message is directed to can open it (confidentiality)

Electronic Trading Partner Agreement Engagement Model Governance Board Electronic Trading Partner Agreement Medicare Australia Health Fund Hospital or Provider HESA Software Vendor Development Agreement Development Agreement PKI Benefit Agreements

Audit and Controls ECLIPSE does not replace existing audit responsibilities. It provides an audit trail via the transaction logging at the client adaptor, server adaptor and the HUB. PKI Infrastructure ensures the message has been sent via a trusted source. Requires a Notice of Integration to be issued by Medicare Australia prior to usage. Data model does not support surfing.

Healthy Statistics Based on BUPA Australia’s experience Error Rate has decreased to 1.85% 95% of claims are processed in 24 hours or less Fastest OPV - 4 seconds, from the practice to Medicare and to the Fund Fastest IMC AG Claim - 3 minutes Call volumes (issues) decreased by 74% ECLIPSE vs Simp Bill

% of Privately Insured Patients covered by an ECLIPSE enabled Health Fund 81.8% 94.3% 90.9% 29.6% 89.6% 95.7% 95.2% Not all these funds have claiming capability but the above does show the funds are committed to developing and using ECLIPSE..

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