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Revision Financing for Healthcare Chapter 1-11 (PAYMENT PROCESS (Charge…
Revision Financing for Healthcare
Chapter 1-11
SG's Healthcare challenges
Increasing demand for more affordable healthcare services
Increasing demand for more healthcare services
Ageing population
Increasing no. of chronic diseases
FINANCIAL ASSISTANCE
3M
MediShield
Low cost national health insurance scheme
To help individual meet large Class B2/C hospitalisation bills
MediFund
Safety net for patients with difficulties paying the subsidised bill charges despite Medisave and MediShield Life coverage
MediFund Silver (2007)
MediFund Junior (2013)
Key Principles
Personal Responsibility
Family Responsibility
Medical Necessity
Many Helping Hands
3 Levels of Approval
Level 1: Pre-qualified cases (Auto)
Level 2: Straight Forward Applications (SF)
Level 3: Non-Straight Forward Applications (NSF)
Medication Assistance Fund (MAF)
To help lower income patients who may not be considered straightforward cases for Medifund
Focus on selected clinically-effective medications that may be expensive
Separate funding from Medifund - to provide more flexibility than Medifund framework
Maximum subsidy level of 75% upon assessment by Medical Social Service
Per capita household income of $1,500 or less
Financial coverage for non-standard drugs
MAF +
Increase maximum subsidy level from 50% to 75% upon assessment by Medical Social Service
Deducted first before using patient's Medifund or Medisave
Expand MAF to cover non-standard(NSDL) drugs
NSDL = Non Standard & Non Formulary
MediSave
Mandatory medical savings account for all Singaporeans/PRs
To help individual set aside part of the monthly income to meet future personal or immediate family's medical expenses.
ElderShield
Subsidies
Govt. Subsidies
CHAS
Purpose
To provide lower & middle income households have access to primary healthcare by bringing affordable healthcare services closer to patients
Subsidy tiers
Green
Pioneer Generation
All pioneer receive CHAS benefits regardless of income or AV of home
Orange
Household monthly per person - $1,101 - $1,800
AV - $13,001 to $21,000
Blue
AV - $13,000 & below
Household monthly per person - $1,100 & below
Subvention
Types
Lump sum subvention
Funds given based on budgetary forecast
Piece rate subvention
Funds awarded based on no. of patient days & volume of outpatient consult episodes consumed. Funding: based on usage.
Casemix subvention
Funds allocated based on DRG. Every DRG depends on complex treatment will command a different amount
Global budget subvention
Funds allocated based on lump sum, piece rate and case mix funding principles
Amount of money given to provide subsidised rates for patients using subsidised services (patients in B2 & C wards)
FINANCIAL COUNSELLING
Means Testing
Target at preventing undeserving "rich" patient from abusing subsidies
Chronic illnesses patients are worried that they might not cope with the financial burden if the existing subsidies is lowered
Steps of MT
1.Consent form: Subsidy for B2/C wards
Consent to release Medisave/ Medishield Life data
Means-test declaration form
Means-test declaration form of family members
Bill
Acknowledge that Financial Counselling was performed
Authorisation of withdrawal/claim of Medisave/ Medishield Life
Payslips & Bank statements
What?
Patient be able to decide
Standard or non-standard options
Seek alternative options at other institutions
Choice of ward (Private/Subsidised)
Proceed or Not with treatment
Informing of estimated bill size of treatment
Intent" Save patients & families from financial burden
Counsel patients on financial impact of medical treatment
Key steps
Previous valid MT available (valid for 1 year)
Authorisation form obtained before MT
Allow them time to decide, it involves a lot of information & complex decision making
MT declaration form
Subsidised charged on chart based on 100% subsidies
Conduct online MT to determine amount of govt. subsidies patient is entitled to.
Patient sign eFinancial Counselling form
Introduced to different class of wards & charges
When?
Patients admitted through A&E (Conducted within 48 hours of admission, diagnosis, treatment patients need at the point of admission may still be uncertain)
Have subsequent changes to the estimated bill size
PAYMENT PROCESS
Billing
Types of Billing
Provisional Bill
Final Bill
Unbilled Staged/Interim Bill
Cancelled or Rebill
Cap for inpatient
Fee Cap
2 approaches
Traditional Method or 2 Individual Fee Caps
Modern Approach or One Major Fee Cap/ 3 in 1
Subsidy Cap
Charge Capture Process
Charge Form
Manual
Disadvantages
Human error & subject to manpower availability
Document to record services rendered to a patient
Automated entry
2 approaches
Centralised
Adv:
Sense of accountability for appropriate charging
Disadv: Possibility of higher cost
Decentralised
Disadvantage
Daily charge reconciliation is delayed
Advantage
Manpower demand is low
2 modes of services codes input
Batch/ Online interface
Batch Interface
BENEFITS
Avoids idling the computing resources
Allows the system to use different priorities
Allows shifting duration of job processing
Allows effective use of manpower & key entries only once
Online Interface
Key concerns:
Services must be performed during length of stay
Zero priced items are allowed
Quantity cannot be zero
Direct entry
Late Charges
Packages
$ Based
Antenatal
Item Based
Deviation from Normal Pricing
Discount Services codes
Surcharge service cost
Conditional Cost
Counter collection
Handover Confirmation
Excess
Shortages
Credit card Collection
Cash Afloat
Claim processing
Various claim systems
Third party claims system
Civil Service
Private
CPF Board
Possible errors
Wrong 3rd party payer
Wrong date of birth entered
Insufficient amount in account
Plan does not cover the service used
Patient no longer eligible
Types of claim
Third party claim
First party claim
Adv
: Payments are guaranteed, Need not pay up front, co-payment by the organisation they belong to
Disadv
: Longer processing time, difficult to keep track of various schemes available, system update need to be done regularly
Denied/Reject claims
Denied Claims
has been processed and the insurer has found it to be not payable
Rejected Claims
Has not been processes by the insurer due to fatal error in the info given
Payment modes
NETs/ NETs CDA
CASH
CREDIT CARDS
CHEQUE
Payment Issues
Reconciliation Issue
Delay in reflecting correct payment status
Refund
Must have credit bal
Scenario
Lapse in service provided
Duplicate payments
Over-charge
Services paid but not performed
Deposit balance from surgery
Return of medications
Partial Refund
MEDICAL INSURANCE
Types
Catastrophic Medical Insurance
Covers major illnesses where the associated amount is substantial.
Works together with basic H&S (hospitalisation & surgical)
MEDISHIELD LIFE
Long Term Care Insurance
Pays a fixed monthly amount for long term nursing treatment
ELDERSHIELD
Private Medical Insurance
2 Forms of Integrated Shield Plans
MediShield Life
Private Medical Insurance Coverage
Provides additional benefits & coverage to the patients when they opt for Class A & B1 wards in public hospitals or private hospitalisation
Limitations
If a patient is covered under more than 1 medical insurance policy, the total claims made by the insured will always be equal to the total medical expenses incurred
Insurance Concepts
Co-payment
Guard against over-consumption
% insured members pays on the portion of the claim above the deductible
Deductibles
Initial amt to pay for claims in a policy year before payout from insurance company/MediShield Life
Avoid first-dollar coverage & help MediShield Life target only large bills
Claim Limit
Maximum amt claimable from insurance policy for each type of expense
EMPLOYEMENT MEDICAL BENEFITS SCHEME
What?
Employed SGreans medical insurance coverage by employers
Assumed sufficient, not inclined to purchase further medical coverage
Issue: employee H&S insurance: not long-term coverage
Disadvantages
Pre-existing illness employee change job
Retirement/unemployment: does not insure, exposed to financial risk when need most after retirement
CIVIL SERVICE MEDICAL BENEFITS
Comprehensive Co-payment Scheme (CCS)
CPW: Most generous; then CSC then MSO
Co-payment on ward Charges Scheme(CPW)
Medisave-cum-subsidised Outpatient Scheme (MSO)
OUTSOURCING
Bank Reconciliation
3rd party billing
Payment posting outsourced to other financing institutions
Debt Recovery
Refund can be processed from the bank