Coordination Committee

1. Coordination Committee Discussion document 31 May 2007

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. Selected feeback from DAMAN and public providers DAMAN • 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 Public Providers

4. 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

5. 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

6. We have talked to a number of people... Output of conversations is captured and made transparent on http://healthstatistics.pbwiki.com (1)Over10 top insurance companies' senior managers during report management process, including ALICO, Arab Orient, Qatar, DNIC, Ahalia, Buhaira, Takaful, RAK, Sagar

7. ... and made signficant progress on our shared agenda • Activity • Status Principles • Agreed(1) • Code an ICD9-CM diagnosis for every encounter • Need a universal minimum data set to make a claim • 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 • Agreed Definitions • Defined minimum Universal claims fields (draft) • Make comments on wiki until 5 June [All] • Finalise claims fields by 8 June [Dr. Finn/Dr. Philipp] • Done • Action needed • Action needed Implement-ation • Develop outpatient ‚cheat sheet‘ • Adapt HAAD reporting (content aligned with universal claims; secure online submission process developed) • Pilot electronic claims (Daman/Al Noor under way; Daman-Al Mafraq agreed) • Start claiming electronically with new claims form [Public Hospital from 1 July 2007] • Shift all all existing claims forms to be fully compatible with universal claims form [All providers by end of year] • Done • Done • Action needed • Action needed • Action needed (1)HAAD, DAMAN, public and selected private providers

8. 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

9. Addressing the Claims Gap Claims gap • 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 Barriers Solution

10. 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

11. Specific proposal for outpatient flat fee • Flat fee for outpatient attendance including all lab and diagnosis („x-ray“) • Prices: • 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%)

12. 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

13. Suggested Roadmap for DRGs Coding • 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) Payment