the insurance process
DESCRIPTION
The Insurance Process. Hafez Atweh Provider Relations Manager. Agenda. Corporate Agreement. Membership. Hospital Agreement & Process. Pre-authorization of Service. Billing of Claims. BUPA Internal Processing. Reconciliation of Accounts. BUPA World Wide. - PowerPoint PPT PresentationTRANSCRIPT
The Insurance Process
Hafez Atweh
Provider Relations Manager
Agenda
• Corporate Agreement.
• Membership.
• Hospital Agreement & Process.
• Pre-authorization of Service.
• Billing of Claims.
• BUPA Internal Processing.
• Reconciliation of Accounts.
BUPA World Wide
• BUPA is a leading independent provider of health services:
– SR 12.8 billion Turnover
– Over 5 million members worldwide
– Professional service to members and corporate management
based on over 50 years of business experience
– Ownership and management of over 600 facilities, including
Hospitals, care homes, screening centers, close care
retirement housing and health clubs
– Employs more then 40,000 healthcare professionals
– Leader in managed care in Australia, Spain and UK
BUPA Middle East
• Operating in Saudi Arabia for 8 years
• 14% Market Share with clients including NCB, Samba, Savola
Makshaff, Proctor & Gamble….etc
• Nationwide hospital & clinic network
• All services and insurance provided in the Kingdom
• Operation Center in Jeddah, Sales & Service in Riyadh and
Khobar
• Employs more than 125 Healthcare Professionals
• Tailored Service system to meet Customer’s needs
Mission
To “Take care of the lives in our hands” as we
provide a trusted and professional healthcare
insurance service to customers,hospitals and
clinics in the Kingdom.
Insurance Definition:
•A contract that provides compensation for specific losses in exchange for a periodic payment. An individual contract is known as an insurance policy, and the periodic payment is known as an insurance premium.
•A formal social device for reducing risk by transferring the risks of several individual entities to an insurer. The insurer agrees, for a consideration, to pay for the loss in the amount specified in the contract.
Sickness Absence
Occupational RisksOverweight
High AlcoholUsage Smokers
Raised CholesterolRaised Blood
Pressure
StressSedentaryLifestyle
DataAvailable
No DataAvailable
Known Issues& Cost
Unknown Issues & Cost
Present But Not Reported,
Measured or Costed
Diet
PMIIll-HealthRetirements
Occupational
HealthLitigation
Visibility of Health Issues
Patients
Insurance Co.
CorporateHospitals
The Employer Needs:
- Value for money.
- Administration taken away.
- Control over cost.
- Healthcare partner.
- Professionalism.
- Improve performance by maximizing the people contribution.
The Employee Needs:
- Accredited healthcare providers.
- Improved customer services.
- Better and more appropriate care.
- Consistency and assurance.
- Support when needed.
- Care and prompt access to providers.
The Healthcare Providers Need:
- Large number of patients.
- Provide wide range of treatments.
- Paid promptly for the services provided.
- Good working relationships.
- Good understanding of the benefits.
- Resolve issues quickly.
Corporate Process:
• Customer “ With a Need “.
• Agree benefits and exclusions.
• Agree Premiums.
• Sign Agreement.
• Notify providers.
• Issue membership cards.
• Distribute Information Pack.
• Start provision of services.
Membership Cards:
Hospital Network
Hospitals & Polyclinics Network through out the Kingdom
Packaged pricing with written contract for Value & Control
Prompt payment settlement with providers
Standards - ICD10 coding
Educational and training workshops
Usage of quality accreditation standards
Direct settlement.
Unit cost and frequency monitor and control.
Pre-authorization of Services:
• Outpatient services in excess of SR1000.
• Inpatient Admissions.
• Day case services.
• Emergency services within 24 hours.
• MRI & CT-scan.
• Dental, Optical, and Maternity.
Monthly Claim Requirement:
• Complete forms.
• Eligible members.
• Medical report.
• Original invoices
• Discount & Deductible collected.
• Results of Lab & Rad. Investigations.
• Group Summary
• General Summary.
Discount & deductible on statement
Discount &
deductible on invoice
Patient’s Contribution – Deductible:
1- Fixed Amount: SR20, SR10
2- Percentage: 10% O/P (Outpatient)
3- Nil.
Deductible Should Be Collected From Net Amount Not From Gross.
Total Incidence(by Volume)
3.0%
97.0%
In-Patient Out-Patient
In/Out-patient Claims
Total Incidence(by Value)
30.0%
70.0%
0
200
400
600
800
1000
1200
0-100 100-200
200-300
300-400
400-500
500-1000
1000-5000
5000-10000
10K-15K
15K-20K
20K-25K
25K-30K
30K-35K
35K-40K
40K-45K
45K-50K
>50K
Value of Claims (SR)
No.
of
Cla
iman
ts
Claims Frequency - By Value
Clinical Coding
• Standardized coding used - ICD 10
• Measurement means management
• Management means standards and comparison
• Performance means Quality of care and Cost effectiveness of care
• Coding means consistent identification of Doctors and hospitals
matched to resources used .
Hysterectomy Abdominal Q0740Hysterectomy and removal of adnexae Q0780
Day 4 no cannulae / lines / cathetersmobilefull diet
Discharge Criteria Day 5All symptoms controlled by oral medication Baseline, BP, pulse and temperature( without antipyretics) Normal diet for 24 hours Passing urine and bowel movements for 12 hours Balance of care lies with nursing staff/ care could be given safely in alternate place of service ADL and needs can be met with or without assistance Patient has received instruction /education and follow up planning
Average LOS for Selected Doctors at Hospital X
Surgical Inpatient Episodes (Aug 99 - Sep20)
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0
Expected
Act
ual
Length of Stay Distribution
Consultant BUPA
W3710 - Total prosthetic replacement of hip joint
0
100
200
300
400
500
600
700
7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
Length of Stay
Nu
mb
er
of
Ep
iso
de
s
0
2
4
6
8
10
12
14
16
18Consultant Y
By Volume
6.1%
0.9%
23.3%
5.9%
7.2%7.6%
11.3%
37.7%
Respiratory system Digestive system
Ear & Mastoid process Examinations (incl. pre-employment)
Skin & Subcutaneous tissue Abnormal clinical & lab findings
Pregnancy, Childbirth & the Puerperium Others
By Value
6.2%
25.7%29.0%
6.2%3.6% 9.4% 4.6%
15.2%
Breakdown of Medical Cases
6.4%
52.8%
15.5%
15.9%
2.4%2.5%
4.5%
Olaya Medical Center - Riyadh Dr S Fakeeh Jeddah
Almana General Hospital - Dammam Almana General Hospital - Khobar
Bugshan General Hospital - Jeddah Dr. Ahmed A. Daghastani Hosp. - Jeddah
Others
Hospital Usage
Claims Value
80.6%
19.4%
Paid in Full Not Fully Paid
Medical Costs - By Value
Reason for Partial Payment
14.9%
13.7%
25.8%
45.6%
Ineligible item
Inappropriate treatment
Non-compliance with contract
Others
BUPA Claims Process:
Provider
CCU
E-claim
Upload Claims
System Adjudication
Medical Adjudication
Technical & Medical QA
Statement
Input Claims
Payment
Customer Service - BUPA process
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