Technology in the healthcare sector

Challenge

The Norwegian Directorate of Health (Hdir) and NAV are responsible for processing health-related reimbursements and automating the exemption card scheme. Exemption cards and e-prescriptions are classified as mission-critical IT systems. To ensure accurate payments and exemption card decisions, they use rule-based solutions.

Requirements:

• Develop a national system for processing and verifyingreimbursement claims from pharmacies and medical supply stores.Calculate amounts and ensure that rates and processing rules comply with Norwegian law and public regulations (the Blue Prescription Regulations).
• Further develop the solution forautomatic exemption cards. Ensure that amounts, processes, rules, services, screen displays, integrations, and operations comply with the requirements and feedback from the Norwegian Directorate of Health, HELFO, and NAV. Ensure the provision of high-quality reports and statistics to the Norwegian Directorate of Health and HELFO.

Solution

Decisive has implemented and further developed these solutions at Hdir / NAV:

• Technical modernization. In 2023, eResept was revamped: We rewrote the application code from Java to Kotlin. All rules were migrated from Blaze Advisor to Kotlin. Previously, we had one large application (monolith), but now we have several smaller apps (microservices), each with its own area of responsibility. This makes the solution easier to manage and further develop. We have also moved away from integration with NAV systems toward integration with Hdir systems. eResept OK is an Hdir-owned system, which will eventually be migrated to Hdir.
• Automatisk Frikort wasdeveloped in accordance with the requirements and feedback from the Norwegian Directorate of Health, HELFO, and NAV.

The eResept OK and Automatisk Frikort applications are closely integrated with Hdir and external partners such as Helsenorge.no, pharmacies, doctors’ offices, Pasientreiser ANS, the Norwegian Medicines Agency, Norsk Helsenett, and others.

The new solutions are written in Kotlin and Spring Boot and run on NAV’s Kubernetes platform (NAIS). The solutions are rule-based, with the rules written in a custom-developed rule pattern.

eResept OK verifies and processes reimbursement claims for blue prescriptions, as well as reimbursement claims for H-prescriptions—that is, health enterprise-funded medications used outside of hospitals. The verification of H-prescription reimbursement claims went live in eResept OK in 2016.

eResept currently has approximately 300 business rules defined by experts.

Consultants from Decisive have contributed by:

• Development Management and Consulting
• Regulatory Architecture and System Design
• Integration and Information Architecture
• Testing, training, and management

Result

ePrescription – among the benefits, we can mention the following:

• eResept OK has been in operation since 2010. The system is used by all pharmacies and medical supply stores nationwide, as well as HELFO. The solution is fully automated and includes the Blue Prescription Regulations integrated into its validation process.
• eResept OK verifies and processes reimbursement claims for blue prescriptions, as well as reimbursement claims for H-prescriptions—that is, health enterprise-funded medications used outside of hospitals. The verification of H-prescription reimbursement claims went live in eResept OK in 2016.
• 130,000 individual invoices are received on average each day from pharmacies and medical supply stores. Claims for blue prescriptions and H-prescriptions in Norway amount to many billions of kroner annually, and claims that cannot be processed automatically are sent to a specialized system for manual processing
• 99.5% automation rate for payments

Automatic tax exemption – the following benefits are worth mentioning:

• Payments are processed as they should be and are closely integrated with other internal systems
• The system is being further developed in consultation with the Norwegian Directorate of Health, HELFO, and NAV.
• Number of payments per year: 2.7 million
• Number of exemption cards issued per year: 1.5 million
• Number of copayments received per day: up to 600,000