The Capital Market Authority (CMA), which regulates the insurance sector as well in the Sultanate, is committed to putting in place a framework of tariff ranges governing the pricing of products and services offered under the Unified Health Insurance Scheme (Dhamani) which is due to be implemented in a series of phases.
The move is designed to limit the potential for fraud, malpractice, and abuse by service providers, insurers, and patients alike when the Dhamani scheme is eventually introduced.
To this end, the regulator – which is spearheading the roll-out of the mandatory health insurance scheme – has floated a tender for the selection of a consultant to undertake a study of tariff structures for a various medical, hospital, and diagnostic products and services offered to patients covered by the Dhamani policy.
“The aim of the tender is to conduct a scientific study in order to build a framework for costing and pricing of health care services reimbursed on evidence-based standards. The outcome of this initiative will reflect industry best practice reimbursement standards, ensuring fairness and sustainability,” according to officials closely associated with the Dhamani initiative.
In an article published in the latest edition of Middle-East Insurance Review, senior CMA officials Ahmed al Maamari, Vice-President (Insurance Sector), and Dr Mohammed Ghazaly, Expert Advisor, said the study is part of efforts to support the implementation of the “initial phase” of the Dhamani scheme.
That effort is being pursued in close collaboration with all concerned stakeholders, including Oman Medical Association (representing the private health care providers), Ministry of Health, Oman Insurance Association (representing the insurance companies), and the Oman Chamber of Commerce and Industry, they noted.
Meanwhile, the roll-out of the Dhamani platform is making headway, according to the Authority. Following a competitive tender floated by the Authority, a contract for an e-Health System, which includes an e-Claims Exchange, has already been awarded.
Explaining the progress made thus far in the establishment of the Dhamani platform, the officials said: “Development work has been initiated aiming at deploying the first phase by 2H2021. This phase will include the implementation of the e-claims cycle comprising complete
digitalisation, automation, and standardisation of health insurance claims. All stakeholders will follow the end-to-end e-claims cycle from submission to payment of claims in electronic format using the Dhamani electronic platform. Some additional features include member eligibility verification, prior authorisation, and basic reporting and analysis of utilisation data.”
In the second phase of the platform’s development, the focus will be on integrating processes such as e-prescription (and pharmacy benefits management), e-referrals (for consultation, laboratory, and radiology), payment gateways, enhancement of data analysis through data warehousing, and the introduction of utilisation monitoring systems to ensure sustainability, the officials stated.
“The third phase will introduce enhanced business intelligence and advanced analytics for quality management, member profiling, advanced monitoring (of fraud, abuse, and waste) and the introduction of member engagement portals, as well as a digital health insurance marketplace,” they added.
Significantly, as many as 490,000 private sector workers and their families — Omani and expatriates — are currently covered by health insurance — a figure that is projected to grow exponentially once the Dhamani scheme is introduced in stages. The number is expected to surge to two million workers and their families when the insurance scheme is fully implemented.
CONRAD PRABHU
@conradprabhu
Oman Observer is now on the WhatsApp channel. Click here
