outer rims...

 

Boss had declared the we would be joining the “outer rim scheme” of the national health insurance bureau plan next year few days ago.

The NHI bureau had started on a claim-pay basis initially. The hospitals submit their bill and the bureau pay as submitted. The bureau has no man power to go through all the cases so it would choose 1 chart per 1000 or per 100 and review the chart. Inappropriate item would be crossed out. The amount of such item would be x 100 (or x1000) and deducted from the payable claim to hospital; that means the chart represent x100 or x1000 of the case note.

The bureau has however allowed the hospital to write appeal for the deduction.

So proper charting is essential, every drug prescribed/exam ordered should be accompanied by appropriate charting.

Under such scheme, some of the hospital had tried very hard to pile up the claim. The annual growth had been enormously high and the govt. had decided to restrict it growth. The bureau had implemented a budget system. 2 schemes were set up -> he inner rim and the outer rim. The budget is separated into 2 pieces. 70% was limited to the budget limit group(inner rim) and 30% to the unlimited group (outer rim) . In the inner rim group, the hospital claim per quarter is set (with reference to claim done during the same period in the past), and a growth of 3-5% is allowed provided the hospital attained the working target set(eg. Total drug cost/total claim <30%....). Any claim beyond the amount would not be paid and the bureau would not deduct any inappropriate item from the claim.

The outer rim portion means the hospital would follow the old rule – claim – review – deduct.2 months before the next quarter, hospitals would have to decided if they wanted to join which portion. If less then 70% of the hospital(counted on claim amount basis) join the inner rim than there would be only one scheme - > the old rule.

Most of the hospital would opt for the inner rim as it is safer and the burden on charting is less. However when a hospital expanded it beds or equipment, the hospital would opt for the outer rim and tried to out perform it past result and gaining chips for bargain in the future.

in the outer rim the deduction rate starts from 20%. That means no matter how good your charting or setting, one would face a minimum deduction of 20% initially and with luck it could be reduce to 10% after appeal.

Not a burden for me but still more time would be spent on typing case note. But I would tried to modified my program. Each time a drug is prescribed an automated generated case note would be done…..and the only job is to print it out….cross my finger……