Health Benefits System goes live
By Tom Pullar-Strecker of INFOTEK
Health Benefits has broken the back of an 18 month $6 million project to streamline claims processing from healthcare providers, and provide better information on how public health dollars are spent.
The Health Ministry business unit processes 64 million claims a year, dispensing about $1.4 billion annually to pharmacists, GP's, midwives and other healthcare providers on behalf of the ministry and district health boards.
Chief operating officer 'AM' says Health Benefits (HB) has gone
live with the first phase of a new computer system, designed to
ensure all claims can be lodged online and processed automatically
as they are received.
The Generic Transaction Processing System (GTPS) is replacing
about 30 separate claims systems. Some require staff to manually
check that claims fall within funding rules. Phase one replaces
the largest of these systems, Pronet, which reimburses pharmacists
for prescribing Pharmac-subsidised drugs. It accounts for 60
per cent of claims processed by HB, both by number and value.
The other systems "a bunch of Oracle systems that where
developed pretty much piecemeal with no overall architecture",
should be replace by GTPS by February under phase two.
AM says GTPS will make it easier for HB to produce reports on
behalf of district health boards, helping them identify deviations
from norms in the pattern of medical interventions they are subsidising.
Other spin-offs include the ability to quickly implement, within
GTPS's rules engine, changes to subsidy policies previously "hard-wired" in
code. Enhanced reporting capabilities in the unified GTPS system
may help in the detection of fraudulent claims by making it easier
for HB to view a provider's overall claiming activity.
Project manager 'DW' says GTPS can receive all claims generated
by clinicians' existing practice management systems. A router,
or workflow manager, then breaks them down into a set of XML-compliant "transactions",
looks for and attaches relevant information held on HB's systems
- such as past claims data and pharmacy schedules which can determine
whether or not the claim is successful - and then passes these
on to a "rules engine" for processing. GTPS runs on HB's
two existing, upgraded IBM AS/400 minicomputers and makes extensive
use of computer language Java.
While GTPS can process claims received on paper, on-line or on
disk, HB's goal - phase three of GTPS - is to enable all pharmacists
and healthcare providers to abandon manual claiming in favour of
a secure e-mail system or the web, using the Government's Health
Intranet for transport and digital certificates for security. DW
says the uptake of e-claiming should be done "at a speed the
sector can manage it, rather than be driven by HB". Lodgement
of claims by secure e-mail has been piloted by 14 pharmacies since
last month. AM says this is proving a success and all pharmacies
which want to submit claims by e-mail should be able to do so by
the end of January. Ninety-four percent of pharmacies submit claims
on diskette for batch processing by HB.
HB also plans to debut a system which lets specialists and GP's
submit claims for "special authority" medicines using
web forms next month. These claims concern reimbursement for drugs
Pharmac has approved in specific circumstances. About 15 staff
are tied up in handling special authorities. "What we are
looking at is putting a form on the web that can be filled in and
approved online." HB will meanwhile give about 75 midwives
access to its "pilot" Oracle and web-based online claiming
system by February.
AM says the claiming system, developed by Wellington software firm SSLnz, will likely be rewritten as a GTPS application next year, once Government rules for maternity finding have been drafted.
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