ow Eclipse November 2010 David Lawrence I feel better now I feel bett
now Eclipse – Journey to Date Key Industry Points • Eclipse stands for ‘Electronic Claim Lodgement and Information Processing Service Environment’ • Eclipse is owned by and run by Medicare Australia as part of their Online Claiming suite. • The industry establishes and maintains the rules – Eclipse Reference Group (ERG) • Medicare Australia manage and oversee testing and access to the Eclipse Hub • Medicare Australia provide IT support and management of Eclipse Hub – including DR and PKI security requirements • All private health funds and DVA are ‘live’ with Eclipse for Medical claims • Growing number of Health Funds and Hospitals using for claims and payments – Medibank Private has over 120 hospitals live and growing I feel better now I feel be 2
now Eclipse – Key Features Hospital Eclipse • All Eclipse submitted records need to be clinically coded prior to submission to Health Fund or DVA • All payments are made via EFT • There a suite of mandated fields and rules within Eclipse • Software used by hospitals must be Eclipse (Medicare) compliant • Hospital Contracts may enable audit function of source documents Medical Eclipse • Channel functions operate – eg MPPA’s, Gap Cover, Billing Agents • All payments via EFT • Suite of mandated fields and rules within Eclipse I feel better now I feel be 3
now Hospital Claim Process (10) ERA sent to Hub (8) Hospital collects assessments (2) Membership Check HUB Hospital System (1) Claim Submitted (4) Membership Check Result (5) Claim sent to Fund (7) HF Assessment sent to Hub (11) Hospital collects ERA Health Fund (3) Membership Check (6) Health Fund Processes Claim (9) Health Fund generates ERA & EFT for Claim I feel better now I feel be 4
now Eclipse – The Road Ahead • Medical • Growth expected as all Health Funds ‘live’ – Medibank Private will be the last for full functionality – Gap Cover (SC) expected June 2011 • Increasing awareness amongst medical providers and software vendors • Hospital • As more Health Funds adopt – growth expected over next 12 -24 months I feel better now I feel be 5
now Eclipse Advantages • Traceability of claim/record • Electronic message/record regarded legally as a ‘document’ • Records/claims for hospitals must be clinically coded prior to submission • Consistent message format to Health Fund – removes ‘fiefdom interpretation’ • Encourages industry alignment re HPPA’s etc • Reduces costs and re-work for all parties • If deployed with ‘rules based’ claims engine – greater rigour in correct payments – ie remove manual intervention • EFT payment aligned with discrete Eclipse Remittance Advice (ERA) – may be uploaded to GL at site Disadvantages • Small providers may be challenged re capital costs • IT support required to set up and maintain I feel better now I feel be 6
Eclipse – Claims Leakage and Fraud How may Eclipse Mitigate? • Internal • “Look Mum- no hands!” • Electronic message direct link to automated rules based engine – Medibank now running at 90% plus STP • Claim ‘interpretation’ is removed • Providers are authorised and vetted twice inbound • Internal staff resources freed up from data entry • External • Transaction ID for all claims/invoices • Eclipse ‘rules’ cross check total charge with component charges • Data/message input is consistent • By running ‘near real time’ early visibility possible • Audit process – desk or at site • EFT payment aligned with discrete Eclipse Remittance Advice (ERA) now I feel better now I feel be 7
now Eclipse – Some Lessons Learnt - Medibank • Eclipse uptake and onboarding is an “enterprise” – ie need to work closely with all parties – Medicare, soft ware vendors, providers/hospitals and funds • Be considerate of change management at both providers/hospitals and fund • Linked and cross functional team – business, claims processing, finance and IT all need to work together to be effective • Significant shared benefits: • No loss of claims • Reduced re-work of claims/invoices • Reduction in time to payment to providers • Immediacy (near real time) of claim assessment • Consistency of inputs as Eclipse has defined rules • If Eclipse linked to a rules based engine, removes capacity for ‘variant’ assessments. I feel better now I feel be 8
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