The Department of Health encourages health professionals to provide cost information to patients prior to admission to hospital or treatment to facilitate Informed Financial Consent. This involves providing patients with an estimate of the full cost of the episode of care from all relevant service providers, including how much of that cost the patient will be expected to pay out-of-pocket.
Online Eligibility Check was designed to support this process by indicating the benefit Medicare and/or their PHI will pay for identified services that can then be subtracted from the total cost to provide an indication of the patient’s out-of-pocket expenses.
OEC allows Healthcare Locations (HCLs) the ability to check the eligibility of a patient in relation to their Medicare and/or Private Health Insurer (PHI) status and obtain an estimate of out-of-pocket expenses relating to:
a hospital stay
prosthetic and miscellaneous services
Medicare Benefits Schedule (MBS) Services
The ability of the OEC functionality to access and collate financial data relevant to the service costs and Medicare and/or PHI benefits applicable to a proposed episode of care can assist a provider in providing the patient with sufficient information for the patient to give Informed Financial Consent (IFC).
There are four types of an OEC request:
OEC – Online Eligibility Check - Medicare and PHI check
o Used by hospitals, day surgeries and medical providers to determine whether the patient is eligible for a selected presenting illness/condition on the admission date. It provides the out-of-pocket expenses for excess, exclusions and co-payments associated with the patient’s hospital product, and the Medicare and the private health insurer benefits payable for the medical services.
ECM - Eligibility Check Medicare - Medicare check
o Used by hospitals, day surgeries and medical providers to determine whether Medicare covers the patient, and which Medicare benefits are payable for inpatient medical services
ECF - Eligibility Check Fund - PHI check
o Used by hospitals and day surgeries to find out whether the patient is eligible for a selected presenting illness/condition on the admission date. This check provides the out-of-pocket expenses for excess, exclusions and co-payments associated with the patient’s hospital product
ECO - Eligibility Check Overseas - PHI check
o Used by hospitals and day surgeries to find out whether the patient who is an overseas visitor is eligible for a selected presenting illness/condition on the admission date. This check provides the out-of-pocket expenses for excess, exclusions and co-payments associated with the patient’s hospital product.
Validations
OECW documents (Medicare Online-Online Eligibility Check.pdf) had defined sets of validations against requests. The CloudPos had implemented UI constraints matching many or most rules to minimize error responses from Medicare Online in order to improve overall UX and reduce traffic with Medicare Online.
[Document notes in Medicare Online-Online Eligibility Check.pdf]