Even if you have heard the phrase "the mandate for online eligibility verification," many directors and staff members have not yet fully sorted out exactly what needs to be addressed and to what extent. This article clearly explains what the mandate for online eligibility verification is, the steps for setup, the subsidies available, and the transitional measures, based on official information from Japan's Ministry of Health, Labour and Welfare (MHLW).
What Is Online Eligibility Verification?
Online eligibility verification is a mechanism that uses a patient's My Number Card (Myna insurance card) or the symbol and number on their health insurance card to instantly verify, online, the eligibility information for the medical insurance they are enrolled in. Previously, insurance cards were checked visually, and treating a patient with a card whose eligibility had lapsed caused claim rejections (returns). With online eligibility verification, the latest eligibility information is queried against the systems of the Social Insurance Medical Fee Payment Fund and the National Health Insurance central organization, reducing erroneous claims caused by expired cards.
Furthermore, with the patient's consent, past medication information, specific health checkup information, and clinical information can be referenced in the exam room. A major value here is that this can be connected to checks for duplicate prescribing and contraindicated combinations, as well as to more accurate care.
The Positioning of the "In-Principle Mandate"
Through a revision of the regulations governing insured medical care, online eligibility verification was, in principle, made mandatory for insured medical institutions and pharmacies starting in April 2023. In other words, medical institutions that provide insured care are, in principle, required to put in place a system that supports online eligibility verification.
However, as the word "in principle" indicates, not all medical institutions are uniformly subject to it. Some medical institutions that are exceptionally permitted to bill using paper rezepts are treated as outside the scope of the mandate. The surest way to determine which category your clinic falls into is to check the official information described below or to confirm with your regional bureau of health and welfare.
Setup Steps
Setting up online eligibility verification generally proceeds in the following flow.
- Create an implementation plan: Consult with system vendors and line providers, and select equipment
- Apply for use: Create an account on the comprehensive portal site for medical institutions and apply
- Prepare the network environment: Set up a closed network for online eligibility verification
- Install and configure equipment: Install face-recognition card readers and eligibility verification terminals
- Connection testing and start of operation: After confirming integration with the receipt computer (rececon) and EMR, begin operation
Integration with the rececon and EMR is especially important. Whether the information obtained at the eligibility verification terminal is automatically imported into the rececon greatly changes the efficiency of reception and billing work. If integration is not smooth, the double effort of manually transcribing the verified information arises.
Subsidies and Transitional Measures
For the setup of the online eligibility verification system, subsidies through the Medical Information Digitization Support Fund have been made available. Because the scope of the subsidy, the maximum amount, and the application deadline change depending on revisions and the fiscal year, be sure to check the latest conditions on the comprehensive portal site for medical institutions or in the official information of the Payment Fund before applying.
In addition, for medical institutions with unavoidable circumstances—such as system preparation not being ready in time—time-limited transitional measures have been provided. Because the categories and deadlines for filing under the transitional measures have also been revised, it is important to refer to the latest official information if there is a possibility that they apply to you. This article avoids stating specific amounts or deadlines definitively and strongly recommends checking the primary sources.
Relationship with the EMR
Online eligibility verification makes reception work more efficient even on its own, but it demonstrates its true value when operated together with an EMR and rececon. When the obtained eligibility information and medication information can be referenced naturally within the chart, and everything connects seamlessly through to rezept creation, transcription errors and billing omissions can be prevented.
AI Karte, developed by Pottech, has an AI-native design with an integrated rececon, allowing everything from eligibility verification to recording and rezept checking to be handled on a single data foundation. The AI rezept check inspects the billing content, and with multi-device support, the same information can be shared seamlessly from reception to the exam room, drawing out the maximum benefit from adopting online eligibility verification. Naturally, as a system that handles medical information, it is designed in compliance with the Three Ministries' Two Guidelines.
In Closing
The mandate for online eligibility verification is not merely about regulatory compliance; it is the gateway to medical DX that leads to greater efficiency in reception and billing and to improved quality of care. Because setup steps, subsidies, and transitional measures change with regulatory revisions, be sure to confirm the latest conditions in official information from sources such as the MHLW, and then proceed with the response in the form best suited to your clinic.
Through providing AI Karte, Pottech serves as the optimal business partner for clinics, supporting not only the improvement of working conditions for doctors, nurses, and medical clerical staff but also the fullest possible realization of what each clinic wants to achieve.
For details, please feel free to contact us.