1. 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

2. 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

3. 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

4. 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

5. 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.

6. 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

7. 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)

8. 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.

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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.

16. 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.

17. 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)

18. 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

19. 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.

20. 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

21. % 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..

22. A health sector eBusiness partnership
Questions?