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SEHA saves money, helps patients by creating payment denial alerts

SEHA Abu Dhabi Health Services Company (SEHA) is saving thousands of dollars a month by making it easier for providers to avoid payment denials from insurance companies. SEHA added detailed alerts to its Cerner-supported electronic health record, and from July 2015 through June 2016 the health system comprised of 2,723 inpatient beds in 12 hospitals and over 65 outpatient clinics saw proton pump inhibitors (PPI) and other medication denial costs drop by an estimated AED 2,820,000 (equivalent to about $767,000 USD).

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 appropriately 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: proton pump inhibitors (PPI) and biological medications. In January 2014, doctors saw AED 1.4 million per month denied for PPI prescriptions alone. Using the new alerts reduced the amount of denials. By July of the following year, insurance denied only AED 0.31 million for PPIs. By July 2016, it had dropped further to AED 0.07 million.

From January through August 2014, SEHA and Cerner changed how the alerts looked and functioned. Originally, doctors saw generic alerts. However, 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 it to ‘ignore alerts,’ 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."

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Client outcomes were achieved in respective settings and are not representative of benefits realized by all clients due to many variables, including solution scope, client capabilities and business and implementation models.