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# Local Shadow # billing # implementation Design of Local framework www.chi.gov.sa ## NER & AWARD CEREMO ## ene in Diritar **ضمان** مجلس الضمان الصحي Council of Health Insurance # Contents * **01** Phases and Deliverables * **02** Shadow Billing Objectives * **03** International Case studies * **04** Key Considerations ## HIMSS 22 19-21 November Riyadh ### Capitalising on Digitisation to Advance Value-Based Healthcare **Moderator** DR NASSER ALIHANI **Speakers** DALID DRAWNEU GORENOWING --- ضمان مجلس الضمان الصحي Council of Health Insurance # AR-DRG implementation and Shadow Billing ## WHAT IS OUR VISION? ## WHAT ARE OUR OBJECTIVES? "To be an international leader in prevention and improving value in health care services for the health insurance beneficiaries" --- ## EVIDENCE BASED AND DATA DRIVEN POLICIES TO ENABLE MARKET AND PROTECT BENEFICIARIES Our aim is to guide the sector towards the North Star * **01** Data-driven & evidence-based policy design * **02** Value-based health care (VBHC) * **03** Improve transparency enable innovation and promote efficiency --- **ضمان** مجلس الضمان الصحي Council of Health Insurance **ضمان** مجلس الضمان الصحي Council of Health Insurance # Project Objectives Implementing foundations for the AR-DRG system across CHI to achieve sustainability and enable payers and providers to improve care services | Guidance | Support | Direction | |---|---|---| | Transparency in provision of care | Detailed understanding of the patient case-mix | Understanding of financial value of services provided | Clear Proof of patient outcomes | ## Process * **Workstream 1:** Project management and Governance * **Workstream 2:** Standards review and recommendations * **Workstream 3:** Clinical Coding & Documentation preparedness * **Workstream 4:** AR DRG preparedness * **Workstream 5:** Shadow billing implementation * **Workstream 6:** Education and awareness of market on case-mix and AR-DRG ## Results * **Awareness and Knowledge:** classification systems, case-mix and specifically AR-DRG system * **Improving Quality:** ICD-10 AM coding quality and standards * **Impact:** AR-DRG implementation * **Preparedness:** AR-DRG implementation and shadow billing Saudi Private Market is Ready Education and awareness are key elements of many of these areas, the project team needs to understand AR-DRG and the implications of the change. Similarly, communication and change management activities should be designed to raise awareness and increase understanding among all stakeholders. ضمان مجلس الضمان الصحي Council of Health Insurance # Phases and Deliverables ## مجلس الضمان الصحي Council of Health Insurance # Proposed plan on introducing AR-DRG in CHI AR-DRG implementation requires piecemeal approach with series of testing and pilots, followed by interdependencies ## 2021 ### Initiation of case-mix * SBS * AR-DRG * ICD-10 AM/ACHI * MDS * Training * Article 11 ## 2022 ### Refresh (strategy & classification) * Updating SBS & AR-DRG * HIM strategy * VBHC strategy * AR-DRG implementation plan ## 2023 ### Market preparedness * Select providers, payers and discrete set of services for pilot * Coding, grouping, MDS, NPHIES * Market Reference Price introduced ## 2024 ## 2025 ### Test & implement * Scale up pilot scope (service & providers) * Further shadow billing * Refinement and improvements * Shadow billing ### AR-DRG billing and reporting * Initiate first billing based on AR-DRG * Regular reporting on case-mix at CHI * Commence VBP pilots  ضمان مجلس الضمان الصحي Council of Health Insurance # Shadow Billing Phases and Deliverables Workstream 5 will be completed in steps as outlined below. Specific details are covered in the project timeline ## Framework * Local shadow billing framework * Workshops * Report on market queries ## DRG Reimbursement * Workshops * Q&A document * Report on market queries ## Shadow billing period * Support claims submission in AR-DRG format to NPHIES * Feedback on completeness of data * Stakeholder engagement workshop and feedback ## Conduct Financial Analysis * Collection of data on a quarterly basis * Analysis of claims & summary statistics report * Premium impact scenarios ## Final pricing framework * Implementation framework ## Activities/Deliverables * Global research * Engage CHI on vision and objectives * Workshop discussion with CCHI for policy directions. * Stakeholder feedback and CCHI sign off on approach. * Stakeholder workshops * Stakeholder engagement workshop report * Data collection tracker. * Data quality report on completeness and accuracy of claims submissions * Stakeholder workshops * Recommended performance metrics * summary statistics from the analysis of shadow billing claims * Report on the analysis of pricing parameters i.e.base rates, relative weights, and funding rules * Report of funding rules and pricing framework --- * Not yet started * Work in progress * Complete **ضمان** Council of Health Insurance # The Shadow Billing phase Patients should seek health services as they would currently. There should be no change in the system from the patients' perspective. TPAs/Insurers should provide feedback to providers regarding issues with data submitted, eligibility checks and claims that would be rejected or not reimbursed in full. CHI will monitor the quality of the data submitted by providers and prepare feedback on required improvements. In addition, CHI will monitor various metrics to identify any changes in patient or provider behavior during the shadow billing period. Providers should deliver healthcare services as they would currently. TPAs/insurer should process the data submitted by providers as they would under a live system, including checking eligibility, benefit entitlements, clinical necessity and allocating claimed amounts to be paid by the insurer or patient, or amounts to be rejected. The system should be assessed each quarter during the shadow billing framework to determine readiness for full implementation. Providers should ensure that all relevant clinical coding, pharmacy details and other data is captured for every service delivered for every patient in line with the data standards and structure put in place by CHI. Providers must submit all relevant data required by the NPHIES. The submission of data should happen frequently within timelines defined by CHI. The shadow billing process should continue until complete quality activity data is available for at least a one-year period. The system should then be reviewed to identify any changes required for full implementation. ضمان مجلس الضمان الصحي Council of Health Insurance # Shadow Billing Objectives <p align="left"> <img src="https://i.imgur.com/12345.png" alt="Logo"> </p> <p align="left">مجلس الضمان الصحي</p> <p align="left">Council of Health Insurance</p> # Shadow Billing Objectives Shadow billing involves using both the existing fee for service pricing system and the new AR-DRG reimbursement system simultaneously. This is a testing phase where selected payers and providers will apply AR-DRG to better understand case mix of services provided and potential financial implications prior to full implementation. ## Parallel collection claims * **Fee for Service** * **AR-DRG Reimbursement** This approach helps to collect accurate data, report on any financial changes, and model the impact of changes that may occur when implementing AR-DRG system. * **Assess readiness of the health system** Data, systems, people and processes * **Assess financial impact** * **Monitor changes in the system** For example, behaviour changes by provider * **Facilitate development and prep for full implementation**  ضمان مجلس الضمان الصحي Council of Health Insurance # Objective 1: Assess readiness of the health system The shadow billing period will be used to ensure that all components of the health system are in place and ready for the full implementation of the AR-DRG reimbursement framework. ## Data Data should capture all required data elements clinical coding, relevant dates, financial information. Providers should submit complete and accurate data to NHPHIES, data should be available to TPA and CHI on a live basis. ## Systems and Processes Updates to systems required including clinical coding, data integration, costing, RMC, data submission to NPHIES. Payers/TPA need to ensure systems for pre-auth, claims process are all in place. ## Pricing Framework The underlying clinical coding and funding framework need to be well defined prior to start of the shadow billing period. Various parameters will be reviewed and updated as more experience is gathered during the shadow billing period. ## Monitoring Framework A monitoring framework should be established to identify any deviations of experience from expectations and inform change/updates required in various components of the system **ضمان** مجلس الضمان الصحي Council of Health Insurance # Objective 2: Assess financial impact One of key objectives of the shadow billing period is to assess the financial impact of the implementation of AR-DRG reimbursement on all relevant stakeholders | | | |---|---| | **Collection of all activity data** | Complete activity data will be submitted by providers to NPHIES, processed by the TPA/Payers and then collected by CHI to perform monitoring of the system and financial impact analysis. | | **Development of a financial impact model** | Milliman will develop a financial impact model using the activity data collected to allow modelling of different reimbursement parameters, including relative weights and base rates for AR-DRG reimbursement, to assess the impact on the health care budget as well as on the revenue of the different providers. | | **Review of the funding framework** | The data collected during the shadow billing framework and the financial impact model will be used to review the reimbursement parameters, including the relative weights and base rates used for AR-DRG reimbursement. | Will providers submit AR-DRG format in NHPIES or data from NHPIES will be used to grouping into AR-DRG by CHI? ضمان مجلس الضمان الصحي Council of Health Insurance # Objective 3: Monitor changes in the system Based on studies on global experience, we expect that there will be some unexpected changes in the system as all stakeholders enter the shadow billing period. A common example is provider behaviour where changes can be observed in both coding practices or admission procedures. | | | |---|---| | Data | A number of metrics should be monitored to assess changes in the system over time, including proportion of encounters by severity level, case-mix, readmission rates, amongst others. | | Stakeholder engagement | Clear communication channels should be established during the shadow billing period to allow for stakeholders to raise any issues or queries through official channels as and when they arise. | | Training and support | Offering training programs and ongoing support to stakeholders will help support consistency across different providers | | Interventions | The shadow billing framework or the system may need to be refined to address or correct any adverse experience during the course of the shadow billing period. | ضمان مجلس الضمان الصحي Council of Health Insurance # Objective 4: Facilitate development and prep for full implementation Implementing various processes during the shadow billing period will help with identifying which areas of the system need support in the preparation for full implementation. | Data structure | Assess any additional data fields to be included in the data specification. | |---|---| | Coding standards | Identify any changes required to the clinical coding standards, including any gaps that should be filled for services that are not currently covered by the coding standards. | | Pricing framework | Review and update the pricing framework including the relative weights, base rates and funding rules beyond what have been considered so far – e.g. outlier reimbursement, add-on price list. | | Systems and processes | Identify any gaps or inefficiencies in the existing systems and processes to close the gaps or improve processes. | | Clear regulations | CHI should ensure that regulations clearly define the system requirements, responsibilities of stakeholders, and timelines that should be met. | | Stakeholder engagement | CHI should facilitate regular stakeholder engagement to ensure that stakeholders are aligned, and that any challenges or queries that emerge can be dealt with quickly and also consistently across the different stakeholders. | | Regular reporting | It is important to ensure that stakeholders are kept updated as to the progress of the shadow billing period. | | Develop process for future reviews and updates | The AR-DRG system will need to be updated in future on periodic intervals. The process for that should be set up during shadow billing as various components such as base rates, relative weights and classifications are identified. | مجلس الضمان الصحي Council of Health Insurance # International Case Studies <p align="left"> <img src="https://i.imgur.com/12345.png" alt="Logo"> </p> مجلس الضمان الصحي Council of Health Insurance # Overview During the development of the shadow billing framework for CHI we have considered the experience of other systems globally. These systems are detailed below: ## 1. Implementation of DRG reimbursement in Abu Dhabi, UAE * DRG reimbursement using 3M's IR-DRG grouper was implemented in 2010 on a pilot basis to a single facility, and then transitioned to mandatory for all private and public facilities from 2013. ## 2. Implementation of DRG reimbursement in Dubai, UAE * DRG reimbursement using 3M's IR-DRG grouper was implemented in September 2020 following a shadow billing period of almost three years. Prior to 2020, inpatient activity in the Emirate was reimbursed on a fee-for-service basis. ## 3. Implementation of DRG reimbursement in Germany * Germany implemented DRG payments in 2003 from following a 3-year transition period from per diem charges, activity-oriented payments, and procedure fees. ## 4. Implementation of activity-based funding in Ireland * The Irish public health system announced the transition from block budget funding for hospitals to activity-based funding in 2012. An initial transition plan was put in place for the period from 2015 to 2017 ## 5. Implementation of DRG in USA * DRG adoption in the US began in the 1970s ad was adopted by Medicare in the 1980s. DRGs adoption continues to increase, though is not yet universal مجلس الضمان الصحي Council of Health Insurance # Abu Dhabi, UAE The Emirate of Abu Dhabi provides full medical coverage to all nationals of the United Arab Emirates (UAE) living in Abu Dhabi under its Thiqa program. Inpatient care is provided through all hospitals (public and private). DRG reimbursement for inpatient services was first implemented from the end of 2010, and then mandated in 2013. IR-DRGs developed by 3M were adopted. This was mainly driven by high claim rejection rates, in addition to overuse of the fee for service payments. The Abu Dhabi DRG reimbursement mechanism is maintained by the Department of Health, Abu Dhabi. Some of the characteristics of the DRG are noted below. > Only inpatient acute cases are included in the DRG reimbursement, while day cases are excluded. Transferring facilities receive a per-diem payment based on the services provided. The receiving facility receives DRG reimbursement * IR DRG are based on ICD 10 CM and CPT codes * Reimbursement is based on a market standard base rate and a hospital negotiates an adjuster between 1 and 3 based on their ## Transition strategy * Initially, DRG payment mechanism was implemented one pilot facility, the Sheikh Khalifa Medical City. Since 2013, DRGs became mandatory for reimbursement of all inpatient visits in public and private hospitals. * All providers and payers are required to sign a standard contract that uses DRGs to pay for inpatient services. The contract specifies a base rate per inpatient stay with a room to negotiate. * There is regular updates to relative weights in 2–3year cycles. * Currently provider quality monitoring exists but is not linked directly to DRG payment. مجلس الضمان الصحي Council of Health Insurance # Dubai, UAE DRG reimbursement for inpatient services was implemented in September 2020 following a shadow billing period of almost three years. Dubai, like Abu Dhabi, uses IR-DRGs developed by 3M which rely on ICD10-CM and CPT codes. The timelines for full implementation of DRG reimbursement in Dubai are shown below: | 2016-17 | Feb 2018 | 2019-20 | Sep 2020 | Apr 2022 | Year | |---|---|---|---|---|---| | Clinical coding standards and improvement of coding in the market. | Start of IR-DRG shadow billing. | Full implementation was initially scheduled for Q4 of 2019. | Full implementation of DRG reimbursement was postponed multiple times. | Introduction of DRG reimbursement for day cases. <br> Long stay per diem payment introduced. | Full implementation of DRG reimbursement for inpatient encounters (excluding day cases). | | Preparation for shadow billing including market engagement. | | | | | |  مجلس الضمان الصحي Council of Health Insurance # Dubai, UAE ## Objectives * Support financial neutrality in the change from fee-for-service billing to DRG reimbursement ## Stakeholders * Providers continued to submit claims through the e-claims platform * In addition, a single line per encounter with assigned DRG code and zero billed amount. * Payers and regulators were able to analyse assigned DRG, and underlying activity data to understand variations in service and length of stay * DHA engaged stakeholders through regular communication (circulars/workshops) ## DRG Reimbursement and Financial impact * DRG prices were based on base rate, relative weight and a negotiation factor between 1 and 3.25 * Negotiation was between payer and provider * Shadow billing data allowed the regulator to determine a financially neutral negotiation factor between payer and provider pairs * Payers must submit their agreed negotiation band factors ## Monitoring/Financial Impact * DHA continued to monitor data submissions, * Stakeholder were afforded a chance to compare existing payments in a fee for service environment and DRG * Review of DRG payment parameters before full implementation --- مجلس الضمان الصحي Council of Health Insurance # Germany The Social Health Insurance Reform act of 2000 obliged the self-governing bodies to select a universal, performance related prospective case fee payment system based on DRGs. Germany implemented DRG payments in 2003 from following a 3-year transition period from per diem charges, activity-oriented payments, and procedure fees. The DRG system in German covers all hospitals (public and private) and all payers (public and private) In a pilot phase 2001 the AR-DRG was introduced to 20 hospitals forming the foundation for the G-DRG. Local cost accounting model was developed, the International Classification of Procedures in Medicine of the World Health Organization was converted into the German Operations and Procedures Codification Index Preparation phase 2000-02: Translation and adapting classification catalogues * 2003 – 2004 Budget natural phase of the G-DRG implementation * 2003 Hospitals to switch their billing to the G-DRG system on a voluntary basis * 2004 National hospitals were legally forced to use DRG system for billing inpatient services * The transition period allowed hospitals to adjust and ensure they do not face unexpected losses Convergence phase, from the statewide base rates to a nationwide base rate Base rates hospital specific and gradually adjusted towards the state-specific base rates The statewide rates have been progressively converging to the national corridor مجلس الضمان الصحي Council of Health Insurance # Ireland Activity Based Funding was announced in 2013 in Ireland and AR-DRGs were approved for use for inpatient classification. An implementation plan was put in place from 2015 to 2017. For the first few years of the implementation of Activity-Based Funding, a focus was placed on developing the skills, capacity and infrastructure required to support the change in hospital funding including developing coding capacity and ensuring that there were adequate coders in place for the hospital system. As part of the implementation plan, transition payments were put in place for hospitals whose average price was either above or below the approved national price. Hospitals with a higher cost based were required to work on reducing their average costs over time, and reasons for unavoidable higher costs were investigated. Up to 2023, transition payments are still in place. For the purpose of shadow billing, a “hub and spoke" model was proposed, with activity-based reimbursement being implemented in the hub or central hospital of each hospital group initially, and then subsequently rolled out to the spoke hospitals. However, there was difficulty identifying the hub hospital for each hospital group. The progress towards full implementation has not been as initially planned, with the delays attributed to "significant variability in the quantity and quality of outpatient data and lack of consistency in reporting specifications". مجلس الضمان الصحي Council of Health Insurance # United States Healthcare in the USA is financed by a mixed system of private and public insurance. The Medicare DRG system was introduced in the 1980s in a phased approach allowing time for providers and purchasers to understand the new system. Payments where a combination of the historic payment using the hospital-specific base rate and the DRG payment using based on a national base rate. * **Year 1:** Hospitals would receive 25 percent DRG payment and 75 percent historic payment * **Year 2:** 50 percent DRG payment and 50 percent historic payment * **Year 3:** 75 percent DRG payment and 25 percent historic payment * DRG was based on national base rate, with adjustments to prices to allow for minimum risk to providers * DRG payments initially allowed for operational costs, and progressively incorporated capital costs with adjustments The new payment system were effectively communicated and engaged with stakeholders. Regulations provided formulas of prices and how payments will work Evaluation and monitoring on a regular basis. Refinements were made مجلس الضمان الصحي Council of Health Insurance # International Case Studies - Lessons Learnt | | | |---|---| | **Clarity of objectives or vision** | There needs to be clarity on the vision and objective for transitioning into DRG payments. This along with expected outcomes helps guide the health system during the implementation phases and becomes easier to manage unexpected outcomes. | | **Gradual phase in** | Most countries made changes by following a phased in approach over 3-10 years. KSA may need to make decisions on pilot providers and consider the proposed timeline for shadow billing. The gradual phase in allows for testing and refinement of processes and progression into AR-DRG. This allows time for stakeholders to adjust and realise the benefits of the new payment scheme and put in place necessary changes to systems and processes. A phased in plan should reflect stakeholders, roles and expected timelines for their activities. | | **Monitoring** | Adequate monitoring framework must be in place in relation to quality of care and cost control. For example, ensuring accurate coding, otherwise there may be increased costs due to inaccurate coding. In some cases, providers changed their behavior by discharging early to maximize profits, these metrics will need to be monitored to enable corrective measures to be put in place. | | **High quality of data** | High quality of data is necessary for ensure an efficient system. Coding and costing data must reflect reality. Inaccurate date may lead to under/over payments for providers, impacting patient care. | | **Transparency and stakeholder involvement** | Transparency is key to ensure positive change of behaviour by providers towards efficiency. Stakeholders will be part of the solution. This can be done through consultative workshops, draft policy or framework documents published for comments, detailed explanation of concepts to stakeholders to ensure full understanding. | | **Training** | Training and workshop programs were conducted for relevant stakeholders during the preparation for and early implementation of DRG transition. The focus mainly covering topics such classifications, coding standards, coding quality, DRG system design and grouping algorithms, costing and tariff setting, reporting, and DRG-specific performance monitoring. | مجلس الضمان الصحي Council of Health Insurance # Key Considerations Council of Health Insurance # Pre-requisites مجلس الضمان الصحي Council of Health Insurance # Prerequisites Prior to Commencing Shadow Billing * A clear and flexible pathway towards full implementation of the various reimbursement mechanisms. Timelines should be clearly communicated so that providers understand their obligations. * Coding and data standards should be well defined by CHI and rolled out to all providers. * Systems and processes must be in place for the collection of data from providers. * Base rates and relative weights to be applied for financial impact analysis. These need to be available for market to understand how to apply them and reflect expected future reality as closely as possible. These can be refined as the shadow billing progresses * Roles and responsibilities should be defined and communicated to the relevant stakeholders. * Formal communication channels should be established to ensure that all queries and issues are addressed in a timely manner and consistently across stakeholders. This should include regular workshops with all stakeholders. --- مجلس الضمان الصحي Council of Health Insurance # Stakeholders Council of Health Insurance # Stakeholders We have identified the following stakeholder that are expected to have some role during the shadow billing period. | Stakeholder | High-level description of role # Roles and Responsibilities ## مجلس الضمان الصحي Council of Health Insurance # CHI As the driver of health reform in the Kingdom, the CHI has key responsibilities to fulfill during the shadow billing period. * Providing oversight of the entire system. * Making policy decisions as the system is reviewed. * Publishing regulations including the timelines and parameters of the shadow billing period. * Mandating the required components of the system such as coding standards, data structure, timelines for submission of data and costing methodology. * Facilitating industry engagement and support throughout the shadow billing period. This may take the form of workshops, experience sharing, providing enabling tools, training knowledge sharing, circulars and published documents. * Identify challenges and barriers based on feedback from stakeholders.  ضمان مجلس الضمان الصحي Council of Health Insurance # Milliman/3M Milliman will provide technical support to CHI throughout the shadow billing period as required. * Providing technical support to CHI in implementing shadow billing * Facilitating industry engagement and support throughout the shadow billing period. This may take the form of workshops, experience sharing, providing enabling tools, training knowledge sharing, circulars and published documents. * Monitoring data submitted, ensuring it means expected quality, accuracy and completeness. * Conducting financial impact analysis * Reviewing pricing framework parameters and funding rules * Facilitating industry engagement and support throughout the shadow billing period. 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<br> <br> <br> <br> <br> <br> <br> <br> <br> <br> <br> <br> <br> <br> <br> <br> <br> # Healthcare Payers/Third Party administrators Although no claims will be reimbursed during the shadow billing period, the payers/TPA should prepare all systems and processes that will be required under full implementation. * Develop systems and resourcing to fulfil all required TPA functions in line with the agreed SLA, monitor of both costs and quality of care. Systems/process need to integrate coding guidelines, technical support systems, training, and coding audits. * Receive claims data from providers for notional processing * Verify the eligibility of each service against the approved schedule of benefits * Assess the appropriateness of any treatment/services for the listed diagnosis codes and its convenience for the patient's condition * Provide feedback on data concerns and services/claims that would be declined either fully or partially under the insurance system * Best practice??shadow billing budgets and financial tracking of claims ضمان مجلس الضمان الصحي Council of Health Insurance # Healthcare providers The role of the providers during the shadow billing period is critical as the providers are the source of all data and clinical coding required. ## Healthcare providers must continue to provide health services to the population ### Coding and Grouping - Ensure appropriate coding and grouping is followed * Proper documentation in clinical records * Ensure availability and the training of skilled coding staff * Ensure presence of consistent coding rules ### Data preparation and submission * Ensure that data is populated in the format and structure as required by the NHPIES systems * Submit data to CHI within the required timelines * Review the data taking into account any feedback received from CHI, Insurers/TPA. On data completeness, accuracy and appropriate coding * Establish billing in line with the AR-DRG data format and rules * Update RCM systems and processes ### Cost reporting * Implementation and monitoring of costing mechanisms * Sharing costing output with CHI **ضمان** **مجلس الضمان الصحي** **Council of Health Insurance** # Monitoring Council of Health Insurance # Monitoring During shadow billing, CHI will monitor components of the DRG reimbursement system. Monitoring, evaluation and provision of feedback will enable continuous refinements, adaptation and ultimately lead to improved outcomes. * Establish a Shadow Billing Oversight Committee led by CHI and including all key stakeholders from the market. Representation from providers, TPA or Insurers, NHPIES, other stakeholders such as MOH, Case Mix. * The committee should meet regularly to monitor, discuss and resolve issues as they arise. Establish key performance areas for tracking the success of the shadow billing implementation. These will be monitored and tracked regularly, forming the basis of reporting into the oversight committee. KPIs should cover the following areas. 1) Quality of care – to ensure the system incentives continuous improvements in provision of care. 2) Monitor data quality along three dimensions: completeness, consistency and accuracy. Milliman will identify performance metrics to be monitored through out the shadow billing period. Some of the examples are shown in the next. A document on methodology for monitoring will be shared with CHI. --- ضمان مجلس الضمان الصحي Council of Health Insurance --- # Metrics to be monitored for Provider/Health System The following metrics should be monitored at a provider and system level on a quarterly basis throughout the shadow billing period: | Metric | Description | | :----------------------------------------- | :------------------------------------------------------------------------------------------------------------------------------------- | | Data completeness | A scorecard approach per provider to monitor progress towards complete data submissions | | Overall case-mix index | The change in the average severity of all inpatient cases | | Utilisation rate | The number of admissions per 1,000 lives | | Mix of admissions by severity level | The % of admissions falling under minor, intermediate and major complexity for each MDC and overall | | Average length of stay | The change in average length of stay by AR-DRG, MDC and overall | | Proportion of same day DRGs | The proportion of total DRGs that are day cases | | DRG outlier rates | The percentage of DRGs reimbursed as low and high outliers | | Average # of secondary diagnosis codes | The change in the average number of secondary diagnosis codes per admission by AR-DRG, MDC and overall | | Average number of services for each admission | The change in the average number of services per admission by AR-DRG, MDC and overall | | Number of hospital acquired complications | The number of hospital acquired complications per 1,000 lives by AR-DRG, MDC and overall | | Number of unplanned 30-day readmissions | The number of unplanned 30-day readmissions as a % of all admissions by specialty and overall | | Bed occupancy rates | The percentages of beds occupied by hospital and by specialty | ضمان مجلس الضمان الصحي Council of Health Insurance # Financial Impact مجلس الضمان الصحي Council of Health Insurance # Financial Impact analysis Financial analysis plays a crucial role within the shadow billing phase and informing providers of the results of this analysis gives them time to improve coding and make adjustments to clinical practice before they face the financial consequences of a new payment system. ## Revenue Analysis * Assess the potential impact on revenue by comparing reimbursement rates under the current fee for service payment system with those under the AR-DRG system. * This involves analyzing historical data to estimate how much reimbursement might change for various procedures or diagnoses. ## Case Mix Analysis * Examine the distribution of cases and patient types currently treated at the facility to predict how these cases would be grouped and reimbursed under the AR-DRG system. * This analysis helps in understanding the diversity and complexity of cases. * Also helps to understand how coding practices are evolving ## Financial Risk Assessment * Evaluate potential financial risks associated with the transition, such as revenue fluctuations, cash flow variations, or increased financial exposure due to changes in reimbursement patterns. ## Benchmarking and Comparison * Compare your organization's financial performance and operational metrics with industry benchmarks or similar facilities that have already implemented DRGs to understand potential outcomes and best practices. Regular collection of data from the market on a quarterly basis to feed in financial impact model. **CHI needs to make decision on whether to apply:** 1. one base rate for all providers 2. Differentiated base rates by region or type of provider  Council of Health Insurance # Review and refine مجلس الضمان الصحي Council of Health Insurance # Review and refine Review system by simulating scenarios based on various base rates, funding rules, and other market variables Recommend final pricing framework to be implemented Review process should be based on results from monitoring and feedback by stakeholders. CHI should regularly open channels for communication to be able to adapt and consider alternative options to pricing and funding components of AR-DRG payments Groupers, coding quality and classifications will need to be monitored and updated. ضمان مجلس الضمان الصحي Council of Health Insurance # References Council of Health Insurance # References ## Abu Dhabi: * https://www.mbrsg.ae/getattachment/612734c2-9872-4a96-9674-e624e71aba95/Insights-into-the-Diagnosis-Related-Group-(DRG)-pa.aspx * https://documents1.worldbank.org/curated/en/895741576646353914/pdf/Transition-to-Diagnosis-Related-Group-Payments-for-Health-Lessons-from-Case-Studies.pdf * https://mbrsgcdn.azureedge.net/cmsstorage/mbrsg/files/61/612734c2-9872-4a96-9674-e624e71aba95.pdf * https://www.doh.gov.ae/-/media/Feature/shafifya/analysis/updated shafifya Analysis WebsiteUpdateFormCCS-WU-01-16.ashx * https://oxfordbusinessgroup.com/overview/expanding-coverage-development-comprehensive-health-strategy-boosts-services-and-quality-care * https://www.doh.gov.ae/-/media/Feature/shafifya/Prices/Adjudication-Rules/ClaimsAdjudicationRulesV2012.ashx * https://www.doh.gov.ae/-/media/Feature/shafifya/Prices/Adjudication-Rules/Addendum4 V2012.ashx * https://www.doh.gov.ae/-/media/Feature/shafifya/Prices/Methodology of HCPCS reimbursemen Sep 15 14.ashx **ضمان** مجلس الضمان الصحي Council of Health Insurance # References Dubai: * https://www.isahd.ae/content/docs/GC%2009-2015%20Coding%20Standards.pdf * https://www.isahd.ae/content/docs/General%20Circular%20DRG%20Implementation%2004102017%20v3.pdf * https://www.isahd.ae/content/docs/GC%2001-2018%20DRG%20Implementation%20-%20Phase%20II%20of%20Shadow%20Billing.pdf * https://www.isahd.ae/content/docs/eClaimLink%20General%20Circular%20GC08%202018%20-%20Clarifications%20on%20Collection%20of%20DRG%20Negotiation%20Factors%20and%20Reporting%20Requirements%20of%20DRG%20Financial%20Parameters%2029072018.pdf * https://www.isahd.ae/content/docs/GC%2019-2020.pdf * https://www.isahd.ae/content/docs/GC-21-2020.pdf * https://www.isahd.ae/content/docs/GC%2003%202022.pdf  # References **Ireland:** * https://www.pna.ie/images/mftp.pdf * https://www.researchgate.net/publication/259206372 An economic analysis of money follows the patient * https://assets.gov.ie/40185/74ffe4e1dc104cd6856b5a32375d8d5f.pdf * https://www.medicalindependent.ie/in-the-news/news-features/why-has-introducing-activity-based-funding-been-so-difficult/ * https://www.hse.ie/eng/services/publications/activity-based-funding-abf-programme-implementation-plan-2021-2023.pdf ضمان مجلس الضمان الصحي Council of Health Insurance # References **Germany:** Bundesministerium für Gesundheit (2016). Abrechnung stationärer Krankenhausleistungen (Billing of inpatient hospital services). Retrieved from https://www.bundesgesundheitsministerium.de/abrechnungkrankenhausleistungen.html https://www.ncbi.nlm.nih.gov/books/NBK298834/ https://documents1.worldbank.org/curated/en/895741576646353914/pdf/Transition-to-Diagnosis-Related-Group-Payments-for-Health-Lessons-from-Case-Studies.pdf **USA:** https://oig.hhs.gov/oei/reports/oei-09-00-00200.pdf https://documents1.worldbank.org/curated/en/895741576646353914/pdf/Transition-to-Diagnosis-Related-Group-Payments-for-Health-Lessons-from-Case-Studies.pdf http://medpac.gov/docs/default-source/payment-basics/medpac payment basics 19 hospital final v2 sec.pdf?sfvrsn=0 ضمان مجلس الضمان الصحي Council of Health Insurance # THANKS! <p align="center"> <img src="https://raw.githubusercontent.com/google/generative-ai-docs/main/docs/images/image_placeholder.png" alt="Logo" width="100"/> </p> مجلس الضمان الصحي Council of Health Insurance