• New Zealand Government


    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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