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.
The New Zealand Social Welfare Department, which is now called Work and Income New Zealand – WINZ – retained Venturi to build an Expert Calculator for use by Income Support staff who deal with questions of eligibility, allowances and benefit amounts. While the legislators strive to make the benefits, allowances and taxes as simple to calculate as possible, the net result, in a typical case, is an extremely complex calculation. Typically, an officer of the department will have a folder with 50 pages of notes and rates to guide them through the calculation.
This complexity denied the department the ability to give quick consistent advice, either over the phone or at the counter. Undoubtedly, clients were frustrated by the delays and errors in these manual calculations. The XpertRule calculator gives the officer a simple interface to enter the clients circumstances and calculate the eligible benefits, allowances and amounts, including printing an advice note. The speed of this calculator also allows advice to be given by telephone operators, now a major part of the Departments new strategy. The calculator also provides an explanation of the calculation.
Internally the calculator is very complex. The “cocktail” of robust rule-management techniques built into XpertRule make the system easily maintainable by an experienced programmer. In the opinion of the author the same would not be true of tools like Visual Basic or C++ where the lack of data and process integrity could lead to an unstable application.
The Calculator was given the “Best Software” award by the department, against competition from a Workflow system, Adobe Acrobat documentation system and Intranet. The award was based on a vote by the 3000 front office staff who use the software.
The Calculator opened up one more door for Social Welfare. Using the connectivity capabilities of XpertRule, the calculator connects to the mainframe, allowing current client information to be loaded into the calculator as the basis for “what if” calculations with the client.
By Howard Proops of Venturi Limited, New Zealand.