The Health Insurance Organization of Egypt: Utilization and Case Management
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The document summarizes the utilization and case management program of the Health Insurance Organization of Egypt. It describes HIO's role as the primary health insurer in Egypt and its plans to transition to being exclusively a payer by contracting with healthcare facilities. It outlines the goals of utilization management and case management in ensuring appropriate, high quality and efficient care. It also provides examples of outcomes from implementing these programs, such as reduced healthcare spending and lengths of stay.
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The Health Insurance Organization of Egypt: Utilization and Case Management
- 1. The Health Insurance Organization of Egypt Utilization and Case Management Thomas Schwark, Abt Associates, Inc. Mohsen George , Chief Medical Officer, HIO, Egypt Global Health Council June 16, 2011
- 3. Total Number of Beneficiaries (in thousands) 56% 8.3% 0.5%
- 4. Number of beneficiaries (in millions) Census: June 2010
- 5. Percentage of beneficiaries according to LAWS Census: June 2010
- 19. Outcome of UM/CM in Gharbia governorate: 36% decline in spending on medications Established protocols & guidelines for the top diagnoses & procedures. Concurrent review. Egyptian Pounds
Notes de l'éditeur
- In the beginning it covered 140 000 nationals only, but now the health insurance system covers about 57% of the population (about 48 million), including government & private workers, retired workers, widows, school students and pre-school children.
- In the beginning it covered 140 000 nationals only, but now the health insurance system covers about 57% of the population (about 48 million), including government & private workers, retired workers, widows, school students and pre-school children.
- supplying services to patients and customers through 21 branches all over Egypt From Alexandria to Aswan
- Marcus Tullius Cicero (January 3, 106 BC – December 7, 43 BC), a Roman philosopher
- Through Pre-Certification : Hospital submits form to HIO describing the proposed treatment and the patient identifier HIO confirms that the patient is a current beneficiary HIO confirms that the proposed service is include in the Benefit Package HIO confirms that the facility (provider) is currently contracted with, & specific to the service A document against which the hospital’s claim can be compared Required for ALL admissions Pre-Authorization Is an approval of payment for a proposed service prior to its provision Not required for all Cases Typically limited to high cost services or those where indications are controversial
- Short List of Examples of Value of Case Management Potentially Large Cost Claims All Chronic &/or Progressive diseases. Patient with Multiple Diagnoses Need for Rehabilitation Services exceeding 3 months Judgment !
- Coordinate with Physician on Long Term Plan of Care Including Home Care and Participation of Family Frequent Contact (Telephone and Visits)
- Reduces Financial Risk of inappropriate use of services Excessive Length of Stay Delay in Scheduling Investigations Delay in Obtaining Consultation
- How to Review Medical Records to Determine if the Medical Record Documentation: Supports the Diagnosis Justifies the Treatment & the requested investigations Explains prolonged LOS Supports Continuity of Care Identifies a Potential Complication