Service Bundles

Requirements

The Voucher Scheme implementation in Cameroon is implementaing vouchers for pregnant women to use during the periodic consultations related to their pregnancy. The voucher is designed in the form of a slip, with 7 individual vouchers that each represent one type of service “bundle” (4 ante natal consultations, 1 delivery, 1 post natal consultation for the mother, 1 post natal consultation for the baby). Certain types of complications are also covered by the scheme but not represented with a voucher. They are also grouped in service bundles, however, the individual services and items listed in each bundle are reimbursed on a fee-for-service basis with ceiling. These need to be configured and used within openIMIS (with limits and ceilings).

For the vouchers, the idea of flat fee service bundles becomes important. Indeed, each service bundle (represented by a voucher) includes a set amount of medical services and items need to be given under that bundle. For the Health Facilities (HF) to be reimbursed, it needs to provide all services, tests and drugs listed in the bundle. If it provides less, it will not be reimbursed by the scheme for that service bundle. However, if it provides more than listed in the bundle, it is still reimbursed the same flat-fee. This is something not only used in voucher schemes but also other type of schemes. There is an interest from the government to track the consumption of the individual medical services and items used for each patient in the claim, to make sure the services defined by the government are actually being administered.

For the pregnancy complication services, we would need fee-for-service bundles with ceilings. The individual services and items provided to the patient need to be entered into the system to get the total amount of the claim. Of course, these services and items need to be part of the bundle list in order to be reimbursed. If this is the case, the total amount of the claim is reimbursed, given that it is below the ceiling, otherwise only bundle maximum price is reimbursed.

Specification

Health Facility form

• add comments textfield in the HF edit form to allow the note taking (Reginal Found for Health Promotion) in case of authorization of missing product, which will be displayed during claim review

Service creation

• new dropdown named Type is added

  • options: simple/atomic, flat fee bundle and fee-for-service bundle

• Step 1: simple service only shows current service creation form (current form)

  • first step is to add all atomic services and items (part of the CS scheme)

• Step 2: for both flat fee bundle and fee-for-service bundle

  • a checkbox Manual is displayed close to the price to allow manual change if the price

    • if unchecked then the bundle price is readonly and the price is calculated with above formula

    • if checked the price can be manually edited and any change in services and items lists will not impact the price

    • when unchecked (if it was checked) the formula is automatically applied and the price is updated

  • if this service type selected then the list of atomic services and items (added in step 1) will be displayed as it is displayed in the Claim creation form

    • service name with search

    • quantity

    • price readonly

    • delete button (to be removed from the bundle)

• flat fee bundle only

  • will be second step because dependent on atomic services and items

  • bundle price is calculated based on individual services and items added with the formula SUM(service.quantity*service.price)+SUM(item.quantity*item.price)

  • frequency will be limited to 365 days through configuration

• fee-for-service bundle only

  • bundle ceiling (price) is calculated based on individual services and items added with the formula SUM(service.quantity*service.price)+SUM(item.quantity*item.price)

  • the label for the service price will be changed to Ceiling instead of Price as for a fee-for-service bundle, this is the maximum amount that can be reimbursed, not the total price of the bundle

Service and Items Pricelists Configuration

• The services and items pricelists will be limited only to those services as bundles and items that are allowed to be claimed during the reimbursement creation through configuration

Claim creation

• the services and items will be selected for the HF’s attached pricelists as before

• if a flat fee bundle or fee-for-service bundle is selected

  • quantity is set to 1 and readonly

  • price is readonly and is calculated based on the bundle type

  • the sublist of configured services and items are listed under the selected bundle

    • quantity as 0 (quantity above the service bundle configuration is not allowed)

    • price is readonly

    • explication text input (will be used to recall authorization)

    • no delete button

    • the bundle price is automatically adjusted based on the rule:

      • flat fee bundle: if the quantity is less than the configuration the price is set to 0, if the quantity is higher than the configured quantity, the price will not change and remain at the configured total price

      • fee-for-service bundle: the bundle price will be the sum of consumed items and services defined in the configuration but limited to the configured total ceiling. Quantity of any services and items not used should be set to 0.

    • the DB will register the link of usages of atomic services and items within a claim but will not be use in claim rule based engine or valuation

Claim review

The same view with the additions of the claim creation.

• display comments from HF during claim review

• if authorization then MO can increase quantity to reimburse the specific service/product from bundle

  • If the MO increase quantity to reimburse the specific service/product from bundle the same validation rule should apply (the MO can’t by pass validation rules)

Claim Validation

During submission process and claim rejection valuation , two rules should be checked :

• Flat-fee-bundle : A bundle should fit the requirements of atomic services / items. If quantity are not exactly the same as configured in the bundle , the claim should be rejected

• Fee-for-services : The bundle should be checked to be sure that ceiling are not by passed during the review and submission process. The valuated price of the claim should be recalculate during the validation process