At the core of the relationship
between health care professionals, Patients and the health insurance |
|
 
At the origin of SESAM-Vitale, there was an innovating project
consisting in using new technologies to simplify and accelerate
exchanges, thereby doing away with any paperwork.
Deployed as of 1998, SESAM-Vitale currently links more than 223,000
health care professionals with the Health Insurance System,
for the benefit of millions of insured persons who have the Vitale
card.
- More than 900 million claim reimbursement forms per year.
- This is the smartcard which is the most used in France (given
today to all insured persons and beneficiaries aged 16 and above).
- Reimbursement of the insured person within five days instead
of 2 to 3 weeks (paperwork system).
- Gain in administrative productivity.
| The Groupement
d’Intérêt Economique SESAM-Vitale (Economic Interest Group)
is a service provider whose missions are the technical expertise,
the development and the promotion of the SESAM-Vitale program.
The GIE SESAM-VITALE was created by the partners of the french
Health Insurance to develop common solutions to meet the needs
of all its members, whether they are part of the compulsory
systems or the complementary insurance organizations. |
SESAM-Vitale, an infrastructure incorporating many components:
- 48 million smartcards,
- A telecom network and a message service,
- 230 health software applications,
- 210,000 card readers,
- 25 servers handling the flows,
- 23,000 terminals for card updating.
The daily running of this infrastructure requires a permanent
monitoring of the service level (deadlines, reliability, management
of incidents, etc…).
SESAM-Vitale is a program permanently associating many partners
from high technology, industry and services:
- Smart card industry.
- Software editors and integrators for the Health Care Professionals.
- Hosting services and service providers in the Health sector.
- Internet access providers.
- Smartcard readers industry.
SESAM-Vitale, a program linked with our European partners: GIE
SESAM-Vitale coordinates the European NETCARDS project (simplification
of inter-state procedures).
SESAM-Vitale, a program in constant evolution:
- 20,000 terminals for card updating are implementing at the
pharmacists’ as of mid-2004.
- Feasibility of managing the Classification Commune des Actes Médicaux (C.C.A.M) (Common
Classification of Medical Consultations), a major challenge.
- System available to the complementary
health insurance organizations (direct reimbursement flow by the
Health Care Professional to the private insurance organizations
and social security institutions).
- SESAM-Vitale network.
- In 2006, a new portal will allow to update the individual benefits
of the complementary health insurances within the Vitale card.
| SESAM VITALE,
as an integrator ensuring the system consistency, focuses
on the major tasks indicated below in partnership with industry
and service providers: Piloting large projects, Design of
technical architectures, Integration of solutions in relationship
with industrial partners, operators and editors, Supply logistics
for blank or customized smartcards, Monitoring quality of
service for the overall system, Communicating to our “clients”
and partners (industry and services). |
In practice, in order to anticipate these developments, a new
“VITALE 2” smartcard is currently being designed. Highly
secured, it will include a much larger memory. This new card
will be sent out to beneficiaries as of 2006.
Finally, studies are ongoing to define a new architecture
for the overall system. The aim is to introduce more on line functions
in order to make the system more flexible and upgradeable.
|
How the system works |
|
When health professionals arrive at their workplace, they start
their SESAM-Vitale equipment, insert their health professional card
(called CPS) in the double-slot reader and key in their personal
identification code. The card can be left in the reader all day.
For each insured individual, the health professional uses their
SESAM-Vitale equipment to create an Electronic Claim Form (called
FSE). The electronic claim can only be validated after both
the health professional card and the patient's Vitale card are inserted
in the reader.
| NB: the Vitale
card is not a method of payment; the insured individual must
pay for the consultation at the time of his/her visit. The
SESAM-Vitale system was designed to speed the claim processing
and provide dramatic time and cost savings. By changing from
paper-based to electronic claims submission, the insured individual
no longer needs to submit claims to their local health insurance
center. Each claim is electronically submitted by their health
professional. |
Submission (or electronic transfer) can be performed at any time
of the day. As the heath professional initiates the electronic transfer,
claims are automatically sorted into recipient batches to be transferred
directly to the appropriate health insurance center. Claim submissions
can only be performed by health professionals with a personal identification
card. After a patient’s visit, the health professional is allowed
three days to submit a standard claim and one week for a third party
payer claim. A backup copy of all electronic claims should be filed
for a period of three months.
Via e-mail, the Health Insurance Center acknowledges receipt
of successfully transferred claims (called positive ARL). In case
of unsuccessful transfer, a failure notice (called negative ARL)
is sent to the health professional. In case of unsuccessful third
party payer claim submission, a rejection notice (called NOEMIE
and RSP) is also sent to inform the Health Professionnal that he/she
will not receive payment. For each negative receipt, the electronic
claim must be resubmitted within two business days. |
