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Ophthalmic Payments & Electronic GOS Claims

Ophthalmic Payments & Electronic GOS Claims. Optical IT Suppliers Conference 2 nd March 2010. Lyndon Taylor AOP Director AOP representative to OUG. Ophthalmic Service. Strategic Planning Group (SPG) have overseen an Ophthalmic Payments system since 1995

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Ophthalmic Payments & Electronic GOS Claims

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  1. Ophthalmic Payments&Electronic GOS Claims Optical IT Suppliers Conference 2nd March 2010 Lyndon Taylor AOP Director AOP representative to OUG

  2. Ophthalmic Service • Strategic Planning Group (SPG) have overseen an Ophthalmic Payments system since 1995 • In 2001, the SPG funded the project to migrate to a centralised database accessed over N3 • Data sub-set by PCT/LHB

  3. “Exeter” Payment System • Operated by 7 LHBs in Wales • Operated by 145 PCTs in England • Approx 800,000 GOS1 per month, £16M • Approx 300,000 GOS3 per month, £15M

  4. Drivers for Electronic Links • 16,000,000 claims per year all of which need to be printed, despatched, completed, returned, entered & stored • Over 90% of GOS1s were “Batched” • CFSMS pushing for 100% individual input • PCTs and the Profession wanted progress towards a modern approach • Data already sat there in most practices • Other primary care contractors linked

  5. Barriers • Uncertainty • Regulations require a signed form • Funding for the profession & NHSCfH • Connectivity

  6. How did Links Start • Strategic Planning Group initiated a pilot to discover possibilities • Open invitation to suppliers • Specsavers & Ocuco volunteered • Simple but proven technology • GOS1s & GOS6s initially • Still require a paper claim • Aim was to prove it could work

  7. Initial Work • Agree data definitions • Agree error codes (+150 for GOS1s) • Encryption to NHS requirements • Test mailbox and database created • Supplier accreditation • Agree operational protocols with PCTs • - Specsavers first to give it a go in May 07

  8. Claims Processing • Single point of submission • Claims checked against validation rules, including MoU • Errors sent back to sender via encrypted e-mail response file with error codes • Compliant claims allocated to PCT • Initially manual PCT approval • Subsequently move to auto update

  9. System Availability • Mon to Sat 8.00am to 1.00am • Claims submitted by practices are validated on the hour and half hour • Responses from NHSCfH are sent 15 minutes past and 15 minutes to the hour

  10. Statistics • 203 activation requests • 200 active stores • 110 stores using automatic approval • 42 payment agencies covering 85 PCTs • 2,125,569 legitimate GOS1 claims have been submitted

  11. Benefits • Validation rules the same for everyone • Improved GOS management/reconciliation • 30 minute turnaround time • Statements contain detailed patient listings • Cost savings • Possible duplicate claims identified

  12. Issues • Funding • Requirement for a paper claim • Counter Fraud • PA Consulting report

  13. Current Position • Electronic statements available • Vision Express piloting in Hampshire • Independents live with the Ocuco practice system in: • Shropshire, Cheshire, Hertfordshire • Independents live with Optix practice system in: • Kent, Leeds • Specsavers live all across the nation

  14. Looking Forward • Healthcall about to pilot using the Ocuco system • Professional Bodies are actively looking for acceptable alternative to paper/signatures • Dataset and submission info available (90 pages) • Leave your e-mail address on list with David Craig

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