Using new technology for Information share between HI, Patient and other entities

1. Using new technology for Information share between HI, Patient and other entities Martin ŠEBEK Sofia, February 7-th 2007

2. Topics to be addressed • Starting point • Expectation and Goal • Solution

3. Starting point

4. Where we start with information claims for hospital care ID of insured p. diagnosis procedures length of stay ID of provider Lamb-sum Cost Per Capita / services Services • claims for ambulant care • ID of insured p. • diagnosis • procedures • ID of provider • registration • prescriptions • ID of insured p. • drug code • drug price • ID of provider • ID of pharmacy • specialists • ID of insured p. • diagnosis • procedures • ID of provider • registration

5. Where we start with information • employers • address • account number • list of employees • total payment amount • insured person • change of HIC • eligibility for state subsidy • state administration • unemployed pers. • retired persons • social service recip. • people relocation • birth & death

6. Scope • Insured people ~ 7 M • Health care providers > 34.000 + > 2.000 • Premium payers > 200.000 • Government entities ~ 10

7. 2. Expectation and Goal

8. Goal • Check Health Insurance eligibilityCZ + EU • Check validity of contract • Insured person access to data reported by Health care providers • Yearly statement -> on-line ? • Exchange data between HI and other external entities • Government • Premium payers • Health care providers

9. 3. Solution

10. Architecture Registermanagement Insured people Health care providers Premium contributors Financialmanagement Cash flow Planning & simulation controlling Health Caremanagement HC network mngmt. Insured person info HC information External Communication Paper, file on disk, Portal, B2B Strategy and management level Information exchange hub Claimmanagement Different types ofHC claims & funding Claim check Price calculation Financialoperation general ledger Bank Pair invoice & claims Premiumcollection Different types ofpremium contributors Premium collectioncheck Operational level

11. Functionality • Portal - Extranet • On-line access to EHIC card validation • B to B connection • Services oriented architecture • Adaptation of SW on both sides • Limitation of mistake & increase of speed • Quality of data

13. Health Insurance solution - components • Claim management • types of claim according funding scheme (per capita, fee for service, contracted amount of health care/funds, DRG, …) • checking against contract, catalogues, registers • checking against history • payment calculation • Financial operation • all legal accounting requirements, general ledger, bank • pair invoices with claims, process financial differences • Premium collection • collect premium from all types of contributors (individual people, companies, government, self employed, …) • build and keep list of “Health care eligible/insured people”

14. Health Insurance solution - components • Information exchange hub • ensure information and message transfer between different solution components / applications • ensure data availability and integrity • integrate all operational sites and strategy/management site

15. Health Insurance solution - components • Register management • health care providers, health services insured/eligible people, premium payers • links between registers (per capita, contribution payment, …) • serving all operation sites • link to other institutions in the country • Financial management • Cash-flow across country • Financial planning on the base of trends and history experience • Health care management • unified view on the insured/eligible person (across all services) • unified view on the health care provider (direct, indirect cost, quality, efficiency, …) • source for planning • source for claim and behavior checking