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Claims Management

Claims Management

4 Must-Do’s

1. Problem Description: Have you clearly defined the user problem(s) you intend to solve, and what value this creates? Write down a story, user insight, or quote about this problem (this is important because (1) this will motivate your team, and (2) without this your problem might not actually be a big problem for the users themselves).
2. User Stories: Have you clearly written at least 3 user stories and use cases? 
3. Market Analysis: Have you surveyed what the market is doing here (e.g. comparison to other EMRs, or paper approaches; and don’t forget about learning from historic/existing OMRS instances)? Have you written down any possible gaps in your understanding of your users or their workflows? Have you reviewed the topic in FHIR to see what requirements or fields the global community references? (Eg if working on insurance, should look here)
4. Technical Considerations & Dependencies: Have you outlined what you need from cross-functional areas for success of the feature? E.g. do you need the platform to support a new API call? Have you explained how you’ve addressed dev concerns, such as designs that may not be feasible, or will be extra time-intensive to implement? 

Optional/Encouraged

Sketches: Have you added a drawing or description of how the feature could work to solve the problem at hand? (Pictures of sketches are ok!) 
Project Management: Have you created the Epic and JIRA tasks so you can share work clearly? Roll-out plan: Do you have an idea whether this will be an experiment, gradual roll out, and when? Have you added this to the timeline view? Have you planned how you will promote and/or work with communications folks in order to help this feature reach the widest audience and have the biggest impact it can?

Later but should do

QA Plan: Have you mentioned the plan for QA, such as how you will discover and address edge cases? Does your team/squad have a plan for automated tests to be added to new components (unit tests) or workflows (e2e tests)?
Safety & Tech Risks: Is there any reason you could regret rolling out this feature? (e.g. possible patient harm, heavy tech debt like introducing an unsupported library) Have you thought through the risks for this particular solution? And, how to reduce/address those? 

This checklist was inspired by this article. Additional Business Analyst Resources here.

Status: Requirements in Progress

Technical Complexity: MediuM

Key Objectives:

  • Configurable billing solution for the OpenMRS community (reference)

  • Help facilities to minimize revenue leakage from billing errors and manual processes

  • Provide real-time financial visibility for healthcare administrators

  • Improve patient experience through transparent billing and cost estimation

 

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Billing App in RefApp

Contributors: Victor Olaitan (Axtute Digital Health), Daphine Nalule (METs), Joshua Nsereko(Mandiro), @Fiona Anderson Veronica Muthee (OpenMRS)

1. Problem

🔴 Patient Pain Points

  • Patients lack clarity on their financial obligations before receiving services.

  • Delays in billing and claims processing may disrupt healthcare access.

  • Patients struggle to understand what services they received and associated costs.

🟡 Facility Administration Challenges

  • Healthcare facilities lose significant revenue due to processing mistakes, missing documentation, and faulty claim submissions.

  • Facilities operating without proper claims systems face financial reconciliation problems.

  • Administrators lack clear insight into financial inflows and reliable revenue forecasting.

  • Manual workflows waste staff time and limit administrative oversight.

⚫️ Technical Issues

  • Current RefApp billing module has gaps and bugs with different billing versions across the community.

  • Currently, there is no connectivity/integration with payment systems and insurance providers.

→ Additional notes from Billing Unconference session at OpenMRS 2025 Conference: https://openmrs.atlassian.net/wiki/x/fYCNIw

2. User Stories

Detailed Billing Workflow User Stories

https://docs.google.com/document/d/1onCZXE8TzdjTmWb5pbiBOPih4CT8AdnoXGoYA2uAPZw/edit?tab=t.0#heading=h.x5qfkufc4mgu

📌 Patient:

  • As a patient i want to know my financial responsibility before services are rendered so that i can make informed financial decisions.

    • Ensure the system automatically applies configured rates for services and commodities based on facility-specific pricing rules.

  • As a patient i want to understand the waivers / discounts i qualify for to reduce my financial burden.

    • Ensure the system automatically identifies and presents applicable waivers/discounts based on patient eligibility criteria and configured discount programs.

  • As a patient i want to receive clear bill summaries showing what services i received and the costs associated with them.

    • Ensure the system generates comprehensive bill summaries with itemized services, plain-language descriptions, and detailed cost breakdowns for patient clarity.

📌 Facility Admin:

  • As a facility admin, i want real-time oversight of billing and payment status across all payers so i can track revenue flow and resolve processing delays.

    • Ensure the system displays billing status (total, paid, pending) for effective cash flow monitoring.

  • As an administrator, i want comprehensive billing reports and dashboards so i can track performance, forecast revenue and make financial decisions.

    • Ensure the system provides configurable billing reports and performance dashboards that enable revenue tracking, financial forecasting, and data-driven decision making.

  • As an admin, i want billing summary cards showing key metrics (pending claims and revenue) so i can quickly assess financial situation of the facility.

    • Ensure the system displays key financial metrics through summary cards that provide instant visibility into facility financial health.

📌 Health Facility Staff (Cashier, Receptionist, Nurse, Doctor):

  • As a healthcare provider, i want to capture accurate patient information and services rendered for accurate billing.

    • Ensure the system automatically captures service pricing and patient details within clinical workflows to enable accurate billing without additional data entry steps.

3. Market Analysis

DRC Specific Billing Needs

Epcare (Uganda) key features

Strengths:

Key Features:

Strengths:

Key Features:

  1. Billable services configuration and management

  2. Integrated stock management with cash item pricing

  3. Backend not forked from core OpenMRS

  1. Service configuration

  2. Billing reports

  3. Stock integration

  4. Visit-based billing

  • Stock management - cash item price - reference the stock item under the cash price

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Billable services
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Adding a new service to billable services

 

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Billable commondities
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Adding billable commondities
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Starting visit with billing details included
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Added bill (start visit)
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Bill list
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Bill payment

 

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Editing bill line item
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Cashier home (all patients)
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Cashier home (individual patients)
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Billing reports generation

 

eHospital (Intellisoft) key features

Strengths:

Key Features:

Strengths:

Key Features:

  1. Pre-billing capabilities with unpaid bill alerts

  2. Automatic charge generation/ event-driven

  3. Comprehensive cashier workflow

  4. Simplified billable services configuration and management

  1. Billing alerts for unpaid services

  2. System listens for encounter completion and triggers charge creation e.g order basket billing integration (via extension slot)

  3. Service queues management

  4. A simple template used to add the billable services

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Add charge items
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Service Queues - start visit
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Pop up message for unconfigured services
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Create payment point

 

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Test order billing
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Drug order billing
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Procedure order billing
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Billing History
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Billing alert
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Billing alert → when you proceed to payment
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Billing overview - before payment
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Billing overview - after payment
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Charge items

RwandaEMR key features (PIH)

Strengths

Key Features

Strengths

Key Features

  1. Mature implementation (in use since 2017)

  2. Insurance eligibility verification

  3. Comprehensive workflow coverage

  1. Billable items setup (Labs, Drugs, Consultations)

  2. Insurance rate management

  3. Automatic MOH insurance portal checking

  4. Multi-insurance support per patient

There are two aspects of billing: Administration and Billing

  • Billable items are set up which include: Labs, Drugs, and Consultation type

  • Service price can be entered by finance department at a clinic, doesn’t need a software developer

  • A bill could be Fully Paid, Partially Paid, or unpaid.

  • Users find the reports hard to use, but no complaints about the workflow

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Facility services price management
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Billing admin department
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Facilty service by insurance companies ( Insurances have different rates.)

 

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Each patient needs insurance added when they are registered or when they check in for a visit.

  • During check in the clerk needs to verify that the patient is eligible to use that insurance. This feature is automatically checking the MOH insurance portal. The user doesn’t leave OpenMRS to confirm.

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Today’s registration on the patient chart needs to be set with the insurance that they will be used today. Most of the time a patient will have 2 types of insurances but they can only use one type per visit. This is also done at the reception point.
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Today’s Registration page lets you select the insurance. Some hospitals but not all require a scan of their transfer (this is like a referral to a hospital) and their ID.

 

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When the visit closes, it will also close the Today’s registration
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Doctor will have to do a billing admission (This is for billing and unrelated to being admitted to a hospital. They also do this for outpatient.)

 

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Once the billable consultation or labs are done a bill is generated. The cashier would select the insurance they are using for today’s visit(but may click on all to see if there are any outstanding bills). It would be helpful to them to know which insurance they used during this visit so they know where to find the bill. Currently they just see this screen.
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This is the bills for the patient when they have more than one bill for that insurance.
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This is the bill for today. Each service has a different bill.
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Global bill has all services on one page. This is what is sent to insurance.
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Revert bill will open the bill for editing if it was closed.

Payment screen

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On payment screen if there is an item that is not supposed to be there they will transfer it to private insurance (eg. if it’s not covered by their selected insurance).
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Third party would be when the government is going to pay for you. (eg when a bill is waived)

You can print a bill for a patient and a receipt.

 

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Bill
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Receipt
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Refunds: A bill could be refunded when the patient wasn’t supposed to pay. If a bill is refunded it’s not on the list anymore it’s voided. You can see it on the UI but there is no content.

 

KenyaEMR key features

Strengths

Key Features

Strengths

Key Features

  1. Pre-billing capabilities with unpaid bill alerts, i.e., Pop-up that displays what needs to be paid before the service

  2. Print options - invoice, receipt and bill statement

  3. Payment method specification before service delivery

  4. Mobile and cash payments (SDK push - MPESA)

  5. Centralized billing management interface showing patient billing summaries, outstanding amounts, and quick access to billing functions

  6. Lab and pharmacy charge creation when labs and medications are ordered

  1. Billing alerts for unpaid services

  2. Print feature

  3. Payment selection at check-in

  4. Multiple payment modes

  5. Billing home dashboard

  6. Automatic charge generations

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Payment selection at check-in

 

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Patient billing alert

 

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Bill payment

 

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Print options

 

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Additional payment modes

 

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Mpesa payment

 

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When medications are ordered→ Pharmacy charges created
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When medications are ordered→ Pharmacy charges created
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After payment processing
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Billing home

Main Gaps Identified From Market Analysis:

  • Standardization: There are multiple billing versions across the community and standardization is needed.

  • Limited Insurance Integration: Billing solutions have primarily focused on cash payments except RwandaEMR which has included insurance payment options.

  • Integration Challenges: Lack of standardized APIs for payment processors and insurance systems.

4. Technical Considerations & Dependencies

🧩 Core System Requirements

🧩 Integration Requirements

🧩 Data Requirements

🧩 Core System Requirements

🧩 Integration Requirements

🧩 Data Requirements

Billing Configuration

  • Configure drugs, laboratory tests, procedures, and services with appropriate billing codes

  • Support multiple pricing tiers based on e.g. payment methods (cash, insurance), insurance provider types (government, private) etc

  • Ensure appropriate staff access with audit trails and prevent unauthorized adjustments

Stock/Inventory Integration

  • Billing module should access stock management data to auto-populate billable commodities

  • Prevent billing for unavailable items

  • Track specific batch numbers and expiry dates for pharmaceutical and medical supplies

  • Support recall processes and maintain regulatory compliance

Payment Systems:

  • Enable integration with mobile money services, payment gateways, and multi-currency support for comprehensive payment processing.

Insurance Systems

  • Enable insurance system integration for automated claim processing and payments.

Patient Data

  • Maintain comprehensive payment and billing history.

Financial Data

  • Maintain comprehensive financial transaction records, claim status tracking, and data structure for reporting and forecasting.

5. Implementation Roadmap

Phase 1: Foundation

Phase 2: Enhanced Features

Phase 3: Advanced Integration

Phase 1: Foundation

Phase 2: Enhanced Features

Phase 3: Advanced Integration

Target: Basic invoicing and cash payments

Deliverables:

  • Service catalog management

  • Basic billing workflow

  • Manual payment processing

  • Invoice and receipt generation

  • Basic reporting dashboard

  • User role management

Target: Advanced billing features and basic insurance support

Deliverables:

  • Pre-billing capabilities

  • Insurance eligibility verification

  • Basic insurance claim submission

  • Enhanced reporting and analytics

  • Stock integration

  • Mobile-responsive interface

Target: Full payment and insurance system integration

Deliverables:

  • Mobile money integration

  • Payment gateway connections

  • Automated claim processing

  • Real-time insurance verification

  • Advanced analytics and forecasting

Core Foundation Features

  • Patient Billing Dashboard: Current visit billing status and outstanding balance display ✅

    • Paid, Pending, Partially Paid

  • Basic Service catalog management: Basic service types (Consultation, Procedures, Laboratory, Pharmacy) ❌

    • Consider adopting a charge item template

  • Invoice Generation: Automatic calculation of totals, Line-item billing with service descriptions, Printable invoice ✅

  • Cash Payment Processing: Cash payment entry with amount validation, Receipt generation and printing

    • Validations such as amount paid should not be greater than amount due ✅

    • Billing history in the patient chart should be updated after payments are effected ❌

    • There should be a way to add the discount ❌

  • Basic Reporting: Cash collection summary, Outstanding payments report, Simple financial dashboard

Proposed Improvements

  • Billing Bug Fixes & Improvements : https://docs.google.com/document/d/159_46aHL_Q7S3jhBd9vZQowiZtpXF3dpPKhoMUMdar8/edit?tab=t.0

  • Billing Alerts Modal:

    • Pre-service payment enforcement

    • Reduced surprise payment issues (for the patient)

    • Clear financial status at point of care (for the staff/facility)

  • Automatic Charge Generation/ Event-Driven:

    • System listens for encounter completion and triggers charge creation

      • When a doctor completes a consultation encounter → Consultation fee automatically added to bill

      • When a lab are ordered → Lab order charges automatically created

      • When medications are ordered→ Pharmacy charges created

      • When procedures are documented → Procedure fees created

  • Charge Item Template:

    • Simple, easy to understand and implement

    • Links billing directly to OpenMRS concepts (concept_id)

    • Any OpenMRS concept can become billable

  • Override Capability:

    • Staff can modify or waive charges when necessary

5. Sketches

Billing Features Proposed

https://docs.google.com/presentation/d/1yZC1-M3PikHMOvBULa1JiZ6Ar5BsYyqE4FfRkcAqkzg/edit?slide=id.p#slide=id.p