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Manage Insurance FAQ

What benchmark is used to see the relative placement of the provider on the scoring scale?

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.

Will our results be compared to the same provider type?

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).

How can my physicians be held accountable for patients lack of compliance? Our patient population consists largely out of basic patients and they don’t comply with medication use?

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.

There is lack of clarity of details of the risk adjustment methodology. Is it possible to reproduce the results with the same methodology in-house?

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.

Our scores look bad as we see really sick patients. How are patients’ factors excluded from this analysis?

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.

Where can I find out more about the measure specifications and other important details about the programme?

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.

Are the metrics Daman uses sound?

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.

How does the provider performance metric cycle look like?

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.

How are the results of provider performance going to be used?

The emphasis is on making the performance transparent (i.e., the “Evidence-Based”) to providers and help them identify their areas of improvement.

Where does provider performance stand today?

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.

What are Reasonable and Customary Charges (R&C)?

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.

What are the basic document requirements for claim submission?

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.

What are additional documents which may be requested depending on the type the of service?

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.

How do I submit a claim?

You can submit your reimbursement claim either through Daman app or Daman website.

What does this mean for you as a member?

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:

  • Scenario 1 – If the R&C rate is less than the actual price charged by the Non-Network Provider, the R&C rate is applied in calculating the reimbursed claim payment.
  • Scenario 2 – If the actual price charged by the Non-Network Provider is less than the R&C rate, the actual price rate is applied in calculating the reimbursed claim payment.

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.

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