Local benchmarks are used for quartile placement of the providers for comparison with the market and likely peers. They’re challenging, but achievable to motivate improvement in certain areas for providers who fall behind in performance and wish to keep up with other providers who are performing well.
International benchmarks are used for comparison purpose only and are not used to rank provider performance. International benchmarks are obtained from clinical data registries, payers such as the CMS MIPS quality benchmarks(www.cms.gov) and accreditors such as the National Committee for Quality Assurance NCQA (www.ncqa.org) and Healthcare Effectiveness Data and Information Set HEDIS.
We calculate and aggregate scores at the market level. However, our reports provide the ability to view provider performance not only by provider ‘Type’ but also by ‘Cluster’ (based on similar facility characteristics).
The physician has the responsibility to take the time to educate the patient about his/her medical condition. With proper education, there will be a very few cases in which they will not be compliant. These exceptions would not impact the scoring.
The risk adjustment methodology is detailed in the Medical Quality & Performance (MQP) Metric Specification Manual. Important variables that affect the risk adjusted outcome for any specific metric can be shared on request. However, it will not be possible to recreate exact provider specific results without the results of other providers.
Risk adjustment allows for an “apples-to-apples” comparison between providers by adjusting for differences in patient mix. The goal is to isolate provider performance in a metric from other patient risk factors, like age and gender composition of the patient mix.
All details related to measure specifications, risk adjustment methodology, scoring aggregation and other important details are available in the Medical Quality & Performance (MQP) Metric Specification Manual.
Yes, the metrics are selected from internationally recognized quality assurance systems such as National Committee for Quality Assurance (US), Agency for Healthcare Research and Quality (US), Care Quality Commission (UK) etc. All clinical metrics have been validated by the latest evidence in literature through Advisory Board, Cochrane Reviews. Outcome metrics are risk adjusted using a reliable tested methodology.
We have a standardized process for Metric Selection, Development, Measurement, Review & maintenance cycle, and the data is refreshed biannually. Addition of new metrics and retirement of the old ones continue to happen throughout the life of the programme based on the current practice and market need.
The emphasis is on making the performance transparent (i.e., the “Evidence-Based”) to providers and help them identify their areas of improvement.
We monitor providers' performance through a wide range of clinical, structural, and financial parameters in different care settings. We share and discuss the performance results on a bi-yearly basis. The purpose is to give timely feedback on Quality Improvement areas, thereby supporting the gradual increase of quality in the Abu Dhabi health system. Providers participate in this programme as it provides useful insights to their performance, gives them an opportunity to provide feedback and take suitable action.
R&C charges refer to the average price of a particular treatment across the network of providers for a specific plan. Daman applies R&C rates to claims incurred out of the plan’s network as non-network prices could be quite high and will impact the policy’s renewal premium. So to maintain a balance between treatment access and cost, payment will be on a R&C basis and not on the actual out of pocket cost of the member.
You may be asked to provide additional documents depending on the nature of your claim such as Prescription, police reports, death certificate, referral form, visa copy, airline ticket.
You may be asked to provide additional documents depending on the nature of your claim such as Prescription, police reports, death certificate, referral form, visa copy, airline ticket.
You can submit your reimbursement claim either through Daman app or Daman website.
We encourage members to seek treatments at Network Providers to receive the maximum benefits of your policy. However, in the event that going to non network providers is non-avoidable, the member might not receive the full share of the cost at a non-network provider if the cost of a specific service of this provider is higher than other providers in your plan’s network.
The below scenarios can assist you in understanding:
This has been illustrated below, for a case where 20% co-insurance applies for all covered services in Non-Network Provider: Example – R&C: Consider that a cost for a particular surgery is AED 1000 at a network hospital.