Health Pearl - HMO is a complete operational software package for Health Maintenance Organizations (HMOs) developed and delivered by NiSi.

Background:

Many HMOs in the developing world are struggling to provide efficient care with limited resources provided to them in terms of funds and health care infrastructure. In addition to the financial and infrastructure challenges, many organization are facing additional challenges as part of growth pains in the Insurance Industry. These additional challenges include but not limited to:

• • Lack of integrity among various entities in the health care system and Presence of rampant Fraud.
• • Lack of customer care solutions
• • Lack of quality providers
• • Lack of health education and prevention programs in public health arena
• • Lack of computer systems that address the speficific needs of the Industry

Health Pearl – HMO

was developed keeping the above issues as the primary focus. Its features have been reviewed and guided by Industry experts in countries such as Nigeria and India where the industry faces these and other challenges. The application is designed to address the need for robust Enrollee Registration, thorough treatment authorization process and a comprehensive claim processing module. In addition to these core features, the application package also comes with a customer call/issue/case management process to ensure high rating on customer interaction and satisfaction. The application also has a module to manage and provide care for enrollees that suffer from chronic conditions, the application provides the ability to register and manage the care for enrollees with chronic conditions such as hypertension, by tracking condition of the patient, regular doctor reports, drugs and delivery. The following section highlights the major features of the application.

Features of Health Pearl - HMO

Registration of Enrollees:

• • Option for group enrollee and private enrollee.
• • Principal Beneficiaries and Dependents are registered and maintained as separate individuals for Authorizations and Claims Purpose however they are connected for Premium collection purpose.

ID Card Generation

• • Option for group enrollee and private enrollee.

Plan Management

• • Plan Types
• • Plans (with classes such as Gold, Silver, Bronze etc.)
• • Multiple capitation fee structures based on Plans and Provider quality levels

Provider Information

• • Provider information tracked by
• • Zone
• • State
• • Quality

Corporate (Groups)

• • Group’s categorized based on business type (small, big and medium).

CRM – Customer Issue Management

• • Robust CRM (Customer Relationship Management) system for all participants of your business.
• • Tracks issues in Case Sets and Cases
• • Provides ability to report on time to resolution and other metrics on customer reported issues.
• • Ability to assign and track case/issue resolution.

Authorizations

• • Tracks Authorization by each treatment category and treatment item and the tariff authorized.
• • Authorization is integrated into Claims / Field officer entry / Payments for auditing and processing.

Field officer Reviews

• • Captures Field officer reviews on treatment audits tracked based on Authorization for treatments and also general quality reports.
• • Field officer notes are integrated into Claim and Payment processing to provide the basis for claim review and approval.

Claims

• • Claims entry, approval claims and review of claims through easy to easy interface with drop downs and hyper links for appropriate information.
• • Claims processing is designed with a work follow.
• • Claims entered by Level 1 User
• • Claims reviewed and approved by Level 2 User
• • Claims Approved for Payment by Level 3 User
• • Claims module presents a Bank Schedule and Payment Schedule for all Claim Sets (Closed or Running)

Chronic Care management

• • To help enrollees with chronic conditions to register, communicate and provide necessary drugs to manage health and avoid serious health problems.
• • Registration for Chronic care enrollee
• • Doctor Appointments and reports for Enrollees
• • Tracking the Diagnosis and Condition of the Enrollee
• • Drugs assignment to Enrollees, Dispatch and Delivery Tracking

NHIS Data uploading System

• • A light windows application that interfaces with Health Pearl – HMO to upload the NHIS PDF file.
• • The PDF file contains enrollee information and NHIS provider information. The data load program updates the existing users and providers while entering new users and providers into the database

Robust Reporting and Business Analytics

• • Standard Reports
• • Analytical Reports with features to roll up and/or break down by various dimensions such as Geography, Time etc..

In Summary, HealthPearl – HMO, is uniquely developed to fill the needs of the Industry and provide the power of data to the Organizations to manage their precious resources.