STATEMENT OF PURPOSE PRIMARY CARE REIMBURSEMENT SERVICE
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1 STATEMENT OF PURPOSE PRIMARY CARE REIMBURSEMENT SERVICE June 2018 Version 1.1
2 Contents Introduction... 2 Contact Details... 3 Background... 4 Structure... 4 Reimbursement Service... 5 The National Medical Card Unit... 6 Source of Funding... 7 List of Data Providers
3 Introduction The Primary Care Reimbursement Service (PCRS) a national service and is part of the HSE. It is responsible for making payments to healthcare professionals doctors, dentists, pharmacists and optometrists/ophthalmologists for the free or reduced costs services they provide to the public across a range of community health schemes. PCRS also manages the High Tech Arrangement, which includes payments to suppliers and manufacturers of High Tech drugs. PCRS is responsible for the central reimbursement of drugs to hospitals involved in the provision of national treatment programmes including the National Cancer Control Programme; National Hepatitis C Treatment Programme and MS services. PCRS also manages the National Medical Card Unit (NMCU) which was established in 2011 to assess all Medical Card and GP Visit Card applications at a centralised national unit. In addition, PCRS compiles statistics and trend analyses to various stakeholders, including the HSE, government departments and agencies, media, researchers and members of the public. Such statistics and trend analysis inform policy and strategic decisions. Anne Marie Hoey, Assistant National Director, Primary Care Schemes and Eligibility 2
4 Contact Details Name: HSE-Primary Care Reimbursement Service Address: Exit 5, M50, North Road, Finglas, Dublin 11 Eircode: D11 XKF3 Telephone Number: Fax Number: Websites:
5 Background The HSE- Primary Care Reimbursement Service, was formerly the General Medical Services (Payment) Board which was established in 1972 under the 184/ General Medical Services (Payments) Board (Establishment) Order, It was originally set up to arrange payments centrally for contractors who provide services or treatments to clients on behalf of the Health Boards under Sections 58, 59 and 67(i) of the 1970 Health Act. The tasks allocated to the General Medical Services (Payment) Board under the 1972 Act were as follows: (a) the calculation of payments to be made for services under Section 58, 59, 67(i) of the 1970 Health Act (b) the making of such payments (c) the verification of the accuracy and reasonableness of claims in relation to such services (d) the compilation of statistics and other information in relation to such services and the communication of such information to persons concerned with the operation of such services With the establishment of the HSE on 1 st January 2005, under the 2004 Health Amendment Act, the GMS Payments Board changed to the Primary Care Reimbursement Services (PCRS), and became a business unit of the HSE. In 2011, the National Medical Card Unit was established and became responsible for the centralised processing of all Medical Card and GP Visit card applications. Structure The Primary Care Reimbursement Service divides into two main areas: (1) Reimbursement Service (2) National Medical Card Unit / Eligibility Each area is managed by a General Manager while overall responsibility lies with an Assistant National Director who is accountable to the National Director for National Services within the HSE. 4
6 Reimbursement Service The PCRS is responsible for making payments to Healthcare Professionals, e.g. GPs, dentists, pharmacists and optometrists/ophthalmologists, who provide free or reduced cost services to members of the public across a range of community health schemes. These schemes make up a large part of the infrastructure through which the HSE delivers a significant proportion of Primary Care to the general public. PCRS also manages the High Tech Arrangement, which includes payments to suppliers and manufacturers of High Tech drugs. PCRS is responsible for the central reimbursement of drugs to hospitals involved in the provision of national treatment programmes including the National Cancer Control Programme; National Hepatitis C Treatment Programme and MS services. Vision: To be an excellent and responsive public service Mission: To deliver a first-class service in a consistent, transparent and efficient way Reimbursement of Claims to Healthcare Professionals are made under the following schemes: General Medical Services Scheme (GMS) General Practitioner Visit Card (GPVC) Drugs Payment Scheme (DPS) Long Term Illness Scheme (LTI) Dental Treatment Services Scheme (DTSS) HSE Community Ophthalmic Services Scheme (HSE-COS) High Tech Drug Scheme (HT) Opioid Substitution Treatment Scheme Immunisations for certain GMS Eligible Persons Primary Childhood Immunisation Scheme 5
7 Health (Amendment) Act 1996 European Economic Area (EEA) Discretionary Hardship Arrangements Centralised reimbursement of Outpatient Parenteral Antimicrobial Therapy (OPAT) Centralised reimbursement of Outpatient Parenteral Infusion Therapy (OPIT) Centralised reimbursement of selected high cost drugs administered or dispensed to patients in hospitals The National Medical Card Unit The centralisation of the General Medical Services Scheme took place in The National Medical Card Unit, PCRS processes the various Medical Card and GP Visit Card applications. Vision: To be an excellent and responsive public service Mission: To deliver a first-class service in a consistent, transparent and compassionate way to everyone that engages with the service 6
8 Source of Funding The Department of Health sets out an annual budget (outlined in the Letter of Determination) in relation to community schemes that are operated by PCRS. PCRS s annual funding is included in the HSE s National Service Plan. PCRS is accountable for its budget and spend to the HSE. PCRS is subject to annual external audit by the Comptroller & Auditor General. The Department of Health retains a policy oversight of its operations. List of Data Providers The Primary Care Reimbursement Services has a legal basis under the Health (Alteration of Criteria for Eligibility) Act 2013 to share data with the following organisations: Revenue Department of Employment Affairs and Social Protection The Health Act 1970 provides for the provision of services on behalf of the HSE by service providers. The service providers give details of the services or treatments provided to patients by submitting claims to PCRS. 7
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