Health Insurance Claims Management System

Introduction

The deployment of Claimsure across the acute public hospital sector improves the efficiency and accuracy of private health insurance claims management. It is implemented by HBS Finance and the Office of the CIO. All acute public hospitals are now live.

The Problem

There are currently 48 public acute statutory and voluntary hospitals in Ireland which generate almost €625m worth of income from privately insured patients. In 95% of cases hospitals have a direct payment agreement between Private Insurer and Hospitals.

For example patients who hold a policy with VHI / Laya / Aviva etc would use this policy to cover the cost of inpatient and day care hospital charges. The Hospital would directly bill the Private Insurer on the patient’s behalf and seek reimbursement from Insurers.

Prior to 2012, various studies had noted the HSE took too long to collect this debt. Each hospital had its own way of managing this process, so there were no national standards or national claims management systems in place.

The HSE was in a weak position in dealing with the major insurers, e.g. negotiating changes in business terms at a high level. From a reporting perspective there was no national visibility, or hospital uniformity when reporting on the level / status of private insurance debt.

The requirement to improve the reporting process, its accuracy and timeliness was paramount. For hospitals no permanent record of private insurance claims were maintained which limited hospitals ability to resubmit, track, query or provide additional information to Insurers in any automated way.

The Solution

The HSE developed a specification and ran a public procurement in 2012. Slainte won the tender with their product, Claimsure.

Claimsure electronically manages all aspects of a Hospital’s claim from patient admission to discharge, including e-submissions to health insurance providers. It replaces the existing paper processing of claims and integrates with the Hospital’s admissions and billing systems

The Claimsure system has been developed by Clanwilliam Health /Claimsure Slainte (Ireland) Ltd. It is web based, hosted in the national Data Centre in a virtualised environment, accessible via the NHN. The rollout was managed in 4 phases, starting in late 2012. The last site, Mayo, went live in December 2015. The national project team was made up representatives from HBS Finance, Office of the CIO and Slainte. Each site provided local resources as required.

The Benefits

Claimsure has enhanced both hospital and corporate reporting, increased efficiencies in claims handling, query management and e-submission at hospital level. Patients can electronically sign insurance forms via an epad or tablet device. Consultants can access an electronic secure list of their claims via their HSE approved device, and can electronically sign appropriate claims.

A national report on Private Insurance Claims is compiled by HBS Finance on a monthly basis for inclusion in the HSE Internal Management Report and forms part of the NPOG performance monitoring review process.

A business intelligence reporting facility is being developed based on the Claimsure data, which will allow for centralised national income reporting and management. With continuing changes in Health Legislation and the Private Health Insurance Sector, Claimsure is the Enterprise system which will be adapted and managed accordingly.

It is a credit to all involved that the project is now complete as planned, and will be a foundation for future developments in private patient income management.

Contacts:

Sean Redmond, HBS Finance, GM Income Reporting sean.redmond@hse.ie

Susan Donnelly, OoCIO, Senior Project Manager susan.donnelly@hse.ie