Claims Management In India

Transcription

1 Claims Management In India Shreeraj Deshpande August 27, 2012

2 HEALTH CARE COSTS Fundamental Causes of Increase in Health Care Costs Rapid Medical Technological Progress Increasing Demands for Better Care Ageing Populations. Rising Levels of Remuneration for Medical Personnel and Practice of "Defensive Medicine" or unethical medicine. Medical costs in India are increasing on an average % annually.

3 HEALTH INSURANCE Health Insurance In India Is Transacted BY Non-Life Insurance Companies Life Insurance Companies Specialist Health Insurance Companies Health Claims (Medical Expenses) Management in India done by TPAs In-house Servicing Units of Insurance Companies. Estimated amount of Rs12,000 crores health claims will be settled in

4 An In-house Health Management Team of Future Generali India Insurance Co. Ltd. Internal units of (FGH) Team Call Centre 24 X 7 Helpline li to cater to customer queries Enrolment Cashless Management Claims Processing Provider Management Research and Analysis Pre Policy Underwriting For card issuance and member data management 24 X 7 services with 2 hours Turn Around Time (TAT)** Average TAT of 14 working days** 3750 hospitals and 700 diagnostic centers network Analysis, Feedback & monitoring For retail medical underwriting Centralized Group / Retail Underwriting at hubs **All TAT s subject to availability of complete documentation

5 Health Helpline Health Helpline is a telephonic information resource available to all beneficiaries The Call Centre will be operational for 24 hours a day and 365 days a year The CallCentre Centre will assist members with: Emergencies Eligibility and Status Documentation Support General Information on the member's Health Policy The Call Centre will NOT impart any medical advice on the telephone. Toll Free Phone : Toll Free Fax : E Mail : [email protected]

6 Member Enrolment Each member will be given a HEALTH CARD. Any error must be reported to us immediately. This card entitles the member for identification ONLY as a member. The member must carry a photo identification. This card does not entitle the member to cashless without pre authorization. This is NOT a credit card.

7 Provider Networks (FGH) has its own network of hospitals in all major towns and cities All hospitals are evaluated with respect to the quality of care and adequacy of staffing before empanelment Current network of 3750 hospitals in 26 states tt and 450 cities Diagnostic Centre network of 700 centres in 250 cities Any new hospital to be added can be recommended to us Addition is subject to fulfillment of empanelment criteria

8 Cashless Administration The member will approach the Pre Authorization Cell for any ailment, unless emergency hospitalization is required, and intimate the claim The pre authorization cell will explain process for cashless hospitalization Beneficiary i may seek direct admission i to the hospital li incase of emergencies shall issue an Approval letter after proper scrutiny of the recommendation and determination of the proper expenses Denial letter will be issued for claims not admissible under the policy Claims will be forwarded by the hospitals for approved cases

9 Cashless Process Customer approaches FGH Toll Free for Cashless Treatment. Future Generali coordinates with hospital for preauthorization Hospital verifies customer details and sends pre auth by fax to FGH (Pune) FGH verifies pre auth details with policy benefits and sends the response by Fax to Hospital Network Hospital Approved Query Denial Authorization Letter sent by FGH Query Letter sent by FGH Denial Letter sent by FGH Hospital admits the patient without any deposit and provides cashlesstreatment Hospital faxes the reply for queries asked by FGH doctors Hospital admits the patient as Cash Patient and patient pays the Bill

10 Reimbursement Claim Claims will be forwarded to the Team in Pune by the member /corporate. All claims will be managed by the Claims Team located in Pune. Claims can also be routed through the local branch offices. The claim will be assessed by trained personnel after all documents have been received. All claim payment advice shall be made within 14 working days from the date of receipt of complete documents. Claim payments for retail policies will be sent to the member directly at the address given on the policy. Claim payments for group policies will be sent to the branch office /HR.

11 Preliminary scrutiny of claim & verification : Policy Benefit Date of Loss Mandatory Documents Claim documents received from Insured member Deficient (Some Document required For Admissibility) Repudiated (Not falling with policy conditions) Approved (Admissible under policy) Intimation of the Deficiency is sent to the client Repudiation letter sent to client Payment cheque sent to client Reply received along with all deficient documents Reply not received Subsequent reminders sent at fixed intervals Reimbursement Claims Process Documents not received Claim closed without payment

12 Key Performance Indicators FUNCTION HEALTH HELPLINE CURRENT STATUS 20 Minutes BENCHMARK First response to online queries within 20 minutes MEMBER ENROLMENT 5 Days Cards delivered within 7 days CASHLESS COORDINATION 75 minutes Authorization / Denial within 60 minutes HEALTHCARE NETWORKS 441 cities Presence in all districts CLAIMS ADJUDICATION Average 10 working days Claim processing within 14 working days CUSTOMER SERVICE 20 Minutes Response within 20 minutes

13 Data Analysis & Process Control Trend Analysis For Claims Data For Product Pricing And Definition Claims Analysis For Renewal Of Group Policies Standardized Claims Analysis Formats Profitability Reports For Mid Term Policies Provider Profiling Reports Disease Cost Analysis For Pricing Of Hospital Services Analyze Hospital Utilization, Length Of Stay And Network Saving Statistics And Advise On Product Development

14 Relationship Wise Claims Distribution Relationship Child Parent Self Spouse Claim Frequency 10.19% 15.57% 4.21% 14.86% % Claims (No.) 15.04% 54.66% 9.96% 20.34% % Claims (Amt.) 6.39% 67.50% 8.93% 17.18% 18% 80.00% 70.00% 60.00% Relationship Wise Claims Distribution 54.66% 67.50% Perc centage 50.00% 40.00% 30.00% 20.00% 10.00% 15.04% 10.19% 6.39% 15.57% 9.96% 4.21% 8.93% 20.34% 17.18% 14.86% 0.00% Child Parent Self Spouse Relation Claim Frequency % Claims (No.) % Claims (Amt.) **Data considers entire claims data till 31 st May 2011

15 Age Band Wise Claims Distribution Age Band Above 75 % Claims Count 41.74% 4.45% 7.84% 23.31% 13.56% 5.08% 4.03% % Claims Amount 29.14% 4.20% 10.92% 23.38% 38% 17.39% 8.63% 6.34% Claim Frequency 9.71% 4.92% 7.85% 13.88% 28.22% 21.32% 34.02% **Data considers entire claims data till 31 st May 2011 Excluding Repudiated and Claim Closed without Payment

16 Age Group Wise Average LOS ALOS Per Day Claim Cost Above 75 Grand Total Age Band 0 ALOS Per DayCost Age Group Above 75 Grand Total ALOS Per Day Cost

17 HOSPITAL NAME Hospital Wise Claims Distribution Cost (Top 10) No of Claims Average Cost (`) Total Cost (`) % of Total Cost MANIPAL HOSPITALS % FORTIS HOSPITALS LTD % SAGAR HOSPITALS % APOLLO SPECIALITY HOSPITALS % ASIAN HEART INSTITUTE % ST. JOHN'S MEDICAL COLLEGE HOSPITAL % CLOUDNINE % FORTIS VASANT KUNJ % GRANT MEDICAL FOUNDATION RUBY HALL CLINIC % 2.0% INTERNATIONAL HOSPITAL LTD % **Dataconsiders paid claims only

18 Top 10 Disease Categories Cost Disease Category Wise Claims Distribution Cost (Top 10) Hospital Name Number of Claims % of Count Average Cost Total Cost Obstetrics % Cardiovascular Disorder % Orthopaedic % Pulmonary Disorders % Opthalmology % Oncology % Accidental Injury % Gastrointestinal Disorders % 5.5% Gynaecology % Cerebrovascular Disorders % **Dataconsiders paid claims only

19 Issues In Health Claims Unregulated Health Care Sector. Variation in Prices for Same Procedures Across Different Hospitals in Different Cities Variations in Prices In Same Hospital for Same Procedure Over Different Patients. Hospitals Have Separate Pricing for Insurance/ Non-insurance Patients.

20 Health Claims - Frauds Common Frauds Billing the Insurer for Treatment Actually Not Given to the Cashless Patient. Exaggerated Billing Billing for Consumables Actually Not Used on the Patient. Totally Bogus Documents and Bills. Insured Person Doctor/hospital Nexus. Hospital and Insured Both Involved in the Fraud Tendency of Hospitals to Keep Patients Longer Than Necessary in the Hospital. Hospitals Have Different Rates for Insured and Non Insured Persons. No Medical Management/monitoring Possible Intervention/questioning in Billing Very Difficult

21 Urgent Need Regulations In The Health Care Sector A Very Urgent Need Providers Hospitals To Be Graded On the Basis of Their Infrastructure,,Quality of Service Provided, and Cost Of Treatment Independent/Statutory Agency to Carry Out Such Grading? Can Hospitals / Doctors be accountable to some one? No governments either Central or State have shown any initiatives in this.

22 Strategies - Fraud Claims Management Identify Offices Of High Claims Ratio Identify Areas Of High Claims Ratio Identify Intermediaries Involved. Identify Hospitals Involved Identify Doctors Involved. Profile the Hospitals and Intermediaries Investigate t Through h Professional Investigators t Act Against Identified Persons/Organisations.

23 Data Analysis and Importance Frequency Of Claims Higher Frequency Older Age Group Wider Coverage Maternity In Young Groups Something Is Wrong? Frauds Provider/Insured Related Average Claim Size Geographic Difference Metros Very High Tendency To Visit Large Corporate Hospitals For Minor Conditions Older Age Group Higher Above 40 Years Something Is Wrong? Exaggerated Billings/provider Related Frauds

24 How Do We Control This? Controls At Underwriting Coverage Restrictions Pre-existing/Waiting periods, etc Co-payments And Deductibles Room Type Restrictions/ Room Rent Restrictions Limits on specified conditions. Controls At Claims Cashless Claims Monitoring Spot Visits / Regular Visits Negotiate Packages/Discounts Investigate Suspected Reimbursement Claims Monitor Hospitals

25 Insurance 2 nd Floor, Kant Helix Tower, Bhoir Colony, Opp Tata Motors, Chinchwad, Pune (Maharashtra)