Ophthalmic Payments & Electronic GOS Claims Optical IT Suppliers Conference 2 nd March 2010 Lyndon Taylor AOP Director AOP representative to OUG

Ophthalmic Service Strategic Planning Group (SPG) have overseen an Ophthalmic Payments system since 1995 In 2001, the SPG funded the project to migrate to a centralised database accessed over N3 Data sub-set by PCT/LHB

“Exeter” Payment System Operated by 7 LHBs in Wales Operated by 145 PCTs in England Approx 800,000 GOS1 per month, £16M Approx 300,000 GOS3 per month, £15M

Drivers for Electronic Links 16,000,000 claims per year all of which need to be printed, despatched, completed, returned, entered & stored –Over 90% of GOS1s were “Batched” –CFSMS pushing for 100% individual input PCTs and the Profession wanted progress towards a modern approach Data already sat there in most practices Other primary care contractors linked

Barriers Uncertainty Regulations require a signed form Funding for the profession & NHSCfH Connectivity

How did Links Start Strategic Planning Group initiated a pilot to discover possibilities Open invitation to suppliers Specsavers & Ocuco volunteered Simple but proven technology GOS1s & GOS6s initially Still require a paper claim Aim was to prove it could work

Initial Work Agree data definitions Agree error codes (+150 for GOS1s) Encryption to NHS requirements Test mailbox and database created Supplier accreditation Agree operational protocols with PCTs - Specsavers first to give it a go in May 07

Claims Processing Single point of submission Claims checked against validation rules, including MoU Errors sent back to sender via encrypted response file with error codes Compliant claims allocated to PCT –Initially manual PCT approval –Subsequently move to auto update

System Availability Mon to Sat 8.00am to 1.00am Claims submitted by practices are validated on the hour and half hour Responses from NHSCfH are sent 15 minutes past and 15 minutes to the hour

Statistics 203 activation requests 200 active stores 110 stores using automatic approval 42 payment agencies covering 85 PCTs 2,125,569 legitimate GOS1 claims have been submitted

Benefits Validation rules the same for everyone Improved GOS management/reconciliation 30 minute turnaround time Statements contain detailed patient listings Cost savings Possible duplicate claims identified

Issues Funding Requirement for a paper claim Counter Fraud PA Consulting report

Current Position Electronic statements available Vision Express piloting in Hampshire Independents live with the Ocuco practice system in: –Shropshire, Cheshire, Hertfordshire Independents live with Optix practice system in: –Kent, Leeds Specsavers live all across the nation

Looking Forward Healthcall about to pilot using the Ocuco system Professional Bodies are actively looking for acceptable alternative to paper/signatures Dataset and submission info available (90 pages) –Leave your address on list with David Craig