clim mgt (2)
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HEALTH INSURANCE
By
Rahul Sharma
Fellow With Insurance Institute Of India
MBA-Health managementMSc Computer Science
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Topic To be Covered
1. Review
2. Underwriting In Health Insurance
3. Claims Management
4. Provider Contracting
5. Payment Mechanisms
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Review
What is risk?
What is peril?
What is Insurance?
What is health?
What is health Insurance?
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Claims Management
“Claim is a set of unique transaction that is
done by the policy holder , against the policythat is issued to him/her.”
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Types Of Claims
1. Cashless
2. Reimbursement
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Advantages Of Cashless
Cashless is a very good facility for patients asthey don’t need to pay money at the time of
treatment to the hospital
Patients do not need to run after the insurancecompany/TPA for the payment.
Easy and hassle free as they do not need tokeep any papers of the claims.
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Disadvantages
Patient has to wait till there is no approval formthe TPA/Insurance Company.
As far as hospitals are concern they need to
maintain all the documents related to theclaims of the patients .
Hospitals do not get payment at the time of thetreatment, they need to wait for 21 days to get
the payments.
There are a chance that the bill may be inflatedby the hospital results in exhausting the sum of
the patient
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Advantages Of Reimbursement
Hospital get the payment directly form thepatients.
Hospital do not need to maintains the claim
papers of the patients.
For patient , there are less chance that the billof the patient will be inflated unnecessarily.
Patient Do not need to wait for the approvalform the TPA/Insurance Company.
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Disadvantages
Patients need to maintain all the paper of theclaims
Patients have to follow up with the insurance
company/TPA for payment.
Sometimes because of the lack of knowledge ,patients suffers as they do not have proper
documents.
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Claim Management
Claims MIS
Payment MIS
Claim ratio
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Claim MIS
Month
Date Of Intimation
Transition Id
District
Claim No
Policy No
Hospital Name
Location
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Claim MIS
NOP
HOF
DOA
Package Selected Claimed Amount
Approved Amount
Balance Amount
Final Liability
Float No
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Types Of Claims MIS
Hospital wise Claim MIS
Disease Wise Claim MIS
Policy Wise Claim MIS
District Wise Claims MIS
Daily MIS
Weekly MIS
Monthly MIS
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Claim/Policy Usages Ratio
What is the Claim Ratio
How to calculate claim Ratio
Policy usages Ratio
How To Calculate Policy usages Ratio
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Provider Contracting
What do you mean by service provider inHealth Insurance.
Role Of the Service Providers.
Criteria to select the service Providers.
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Service providers
Hospitals
Day care Centers
Diagnostic Centers
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Criteria To select A hospital
Differ from Insurance company to Insurancecompany, from policy to policy.
Min 6-10 Beaded.
For surgery Min OT, ICU, lab.
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Roles Of the Service Provider
To provide the treatment to the policy holdersas per T&C of the policy.
Maintain the claims documents of the patients.
Maintain the minimum requirement to beempanelled.
Follow the policy T&C ethically.
Proper and continuous reporting toTPA/Insurance company in desired format.
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Issues With Services providers
Ethical Issues
Proper Reporting Issues
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Payment Mechanisms
Claim Intimation
Claim Processes
Claim settled/rejected
Float Raise
Cheque Dispatched/ Online payment
Follow up with the hospital for the confirmation
Dispatching/ mailing a letter with the details ofthe settled claims.
Dispatching the rejection letter to the hospital
with proper stamp and sign to the hospital with
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Float
Float is a set of settled claims done by policyholder against their policy.
Every Float contain a unique no.
Every Float includes all the details of thehospitals including bank details and PAN cardno and also all the relevant details of the
patients.
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Thank You
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