Clalit
Background
Clalit Health Services is one of the largest HMOs in the world providing comprehensive health services to approximately 3.8 million clients in Israel through a decentralized organization comprised of 14 hospitals, 1200 clinics and medical centers, 80 medical labs and 35 imaging institutions.
Challenge
As thousands of services are required daily and as the knowledge regarding patient eligibility for service depends on numerous parameters and changes in accordance with organizational policy, Clalit received incoherent eligibility for service data which was open to differing interpretations. Furthermore, Clalit had no means by which to audit hospitalization bills received from medical clinics other than their own. Clalit organizations had no control over the decision making process whereas any new knowledge (medical, organizational & other) deployment became lengthy and difficult, requiring software expert maintenance.
Solution
The eligibility conditions for any Clalit service, as well as hospitalization bill audit, are implemented using MediRule. The eligibility rules and bill audit rely on interactive dialogue and several parameters: patient demographic data (age, gender etc.), patient medical history, patient insurance type, previous medical services provided, Clalit eligibility rules and other sources of data.
MediRule provides Clalit with online, on-demand, aggregation and integration of information components from dispersed sources and their transfer in real-time to authorized users.
Results
MediRule has enabled Clalit with an efficient and timely process for determining patient eligibility of service. Clalit now possesses homogenous information in all of its centers. This knowledge is shared between all users while new rules are easily and instantly deployed by Clalit users. MediRule has significantly improved Clalit's quality of service towards its patients while preventing the false provision of medical services, potential lawsuits and loss of patients. In addition, MediRule provides Clalit with a budget control & management tool aimed at verifying accuracy of hospitalization periods as well as eliminating unnecessary examinations and treatments given during hospitalization.
MediRule is utilized by Clalit CSRs (customer service representatives) as well, in order to respond to patients calling to inquire about their eligibility for certain services as well as for cross selling – offering additional related medical services.
MediRule is maintained by non technical personnel and has dramatically improved cost effectiveness, quality of service and patient satisfaction within Clalit Health Services.