SEHA saves money and helps patients by creating payment denial alerts
Abu Dhabi Health Services Company (SEHA) is saving thousands of dirhams a month by making it easier for providers to avoid payment denials from insurance companies. SEHA added detailed alerts to Malaffi, its Cerner-supported electronic health record, and in one year the health system saw proton pump inhibitors (PPIs) and other medication denial costs drop by an estimated AED 2,820,000 (equivalent to about $767,000).
The alerts warn physicians if a patient’s insurance company may not cover certain medicines. Insurance companies can deny payment for medications deemed not medically necessary based on the diagnosis or condition – costing the health system. Doctors prescribing medications without documenting an appropriate diagnosis are alerted.
“We wanted to put together a coordinated bundle of clinical decision support alerts, forms and rules that worked together to meet our goals for better patient care quality and improved financial performance,” said group medical informatics director, Gregory Raglow, MD.
The alerts focused on the medication categories costing the most in terms of medical necessity denials: PPIs and biological medications. In January 2014, doctors saw AED 1.3 million per month denied for PPI prescriptions alone, and using the new alerts reduced the amount of denials: by June of the following year, insurance denied only AED 310,000 for PPIs. By July 2016, it had dropped further to AED 210,000 or less monthly. For all categories of medication with denial alerts, denials reduced by more than AED 15.6 million per year.
From January through August 2014, SEHA and Cerner changed how the alerts looked and functioned. Originally, doctors saw generic alerts, but by improving the accuracy, look, detail and functionality, doctors improved the chance that insurance companies paid for prescriptions. The alert fired only when an appropriate diagnosis was not entered.
The alerts are more detailed and more difficult to ignore, forcing doctors to take action.
“We tried to move away from the ‘okay’ button,” said corporate senior clinic application analyst, Ahmed Bekheet.
“Whenever you see an alert you think, ‘how can I get rid of this thing?’ So, we changed the traditional ‘OK’ button to ‘Ignore alert’, because we know most of the doctors would not be comfortable clicking ‘Ignore alert’.”
The new alerts also show SEHA’s doctors the steps they can take to increase the chance their patient will receive the medical care needed, while at the same time ensuring insurance would cover the cost.
“It's about providing value by using clinical decision support tools,” said Bekheet. “By using alerts, rules and modifications, we deliver value for the patient, and also provide financial benefits, reduce payer denials and improve the patient experience.”
The use of clinical decision support has provided SEHA physicians with clear-cut guidance for prescribing highly-effective and high-cost medications. These safeguards ensure accurate use of PPIs, biological drugs, and other medications. This decision support is directly integrated with end users’ clinical workflows to enable them to utilize their time better to support the needs of SEHA.
- Increased compliance with clinical best practice by ensuring medications prescribed for patients align with clinical guidelines for their use.
- Reduction of insurance denials for prescribed medication from AED 1.3m per month in June 2014 to less than AED 210,000 per month in 2017.
- Overall saving of AED 15.6m annually.
- Improved accuracy of targeted provider alerts, thus reducing alert fatigue from unneeded alerts and maximizing the effectiveness of alerts presented to clinicians in their workflow.
SEHA was recognized globally for their achievements on the Value Stage at the 2016 Cerner Health Conference in Kansas City, Missouri, USA, which more than 15,000 delegates from leading health systems in more than 30 countries attended. This Cerner recognition is awarded to the healthcare facilities that demonstrate successful and/or innovative approaches to use of clinical decision support as shown by improvement in patient safety or outcomes.
Abu Dhabi Health Services Company SEHA (saw-ha), which means ’Health’ in Arabic, is responsible for all of the public health in the emirate of Abu Dhabi. Abu Dhabi is the capital, the largest, and wealthiest emirate of the UAE. SEHA has branded their Cerner Millennium® system ‘Malaffi’ (mah-lah-fee), which means ‘My File’ in Arabic.