Presentation to PHIAC Education Sessions. December Samantha Gavel, Private Health Insurance Ombudsman

Transcription

1 Presentation to PHIAC Education Sessions December 2009 Samantha Gavel, Private Health Insurance Ombudsman

2 Role of the Private Health Insurance Ombudsman To provide participants in private health with a reliable system to redress individual and systemic failures. Specific Functions set out under the Private Health Insurance Act 2007.

3 This section establishes the office and sets out the powers and functions of, the Private Health Insurance Ombudsman so that he or she may protect the interests of people who are covered by private health insurance by: assisting people to resolve complaints; and investigating the practices and procedures of private health insurers, brokers and health care providers; and mediating between private health insurers and health care providers; and disseminating information about private health insurance and the rights and obligations of privately insured people.

4 PHIO Responsibilities Deal with complaints; Conduct investigations; Publish information about complaints (SOHFR); website; Report and make recommendations to the Minister or Department about regulatory and/or industry practice; Publicise Office.

5 The Private Health Insurance Industry Complex; Dynamic; Diverse; 37 health insurers; 14 restricted insurers; 6 largest insurers account for 77.7% of the market.

6 Private Health Insurance Complaints Relatively low levels of complaint due to: Consumer focus; Good internal complaints handling systems; Regulation; Utilisation patterns.

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9 Who can complain A person insured under a health insurance policy; A registered health insurer; A healthcare provider (hospital, doctor, ancillary provider, broker, supplier).

10 Complaints can be about: A private health insurer; A healthcare provider (hospital, doctor, ancillary provider, health insurance broker, supplier). Complaints must be about a private health insurance arrangement.

11 Trend - Complaints and Disputes Complaints Disputes Linear (Complaints ) Linear (Disputes) / / / /09

12 Complaint Issues 2008/09 Contract IFC Govt. Incentives Premiums Demutualisation Fund Rule Change Information Waiting Period Membership Service Issues Benefit

13 Dealing with Complaints Seek information from all parties to the complaint; Make a judgement about merits of complaint; Request parties to take action; Negotiate a resolution; Power to make formal recommendation or mediate.

14 Does Complaining Ever Do Any Good? What went wrong? Why? How Could it happen again? Have we fixed it? What have we learnt?

15 Value of Complaints Most dissatisfied customers don t complain; Satisfied complainants become greater advocates than those who ve never complained; Costs of complaints include loss of loyalty, negative word of mouth and damage to reputation.

16 Value of Good Complaints Handling Value of good complaints handling not just to customers, but also to staff; Important to collect AND analyse complaints data; Root Cause Analysis; Prevention.

17 What the Board and Senior Management Should Know Regular reporting of complaints to the fund: - numbers (especially trends) - issues and analysis - outcomes and effectiveness of fund process; PHIO recommendations and fund response; PHIO reports State of the Health Funds Report, Annual Report, Quarterly Bulletins Strategic Positioning on member/customer focus.

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19 Consumer Website ( User Ratings Quality of information Location of information Visual appeal Excellent Good Average Poor Very Poor Ease of use 0% 20% 40% 60% 80% 100%

20 Current PHIO Issues and Priorities SOHFR due for release March 2009; Website refresh for MPPAs with Pathology Providers Acute Care Certification Detrimental Rule Changes Policy Restrictions Consumer Fact Sheets Industry Education

21 Samantha Gavel Private Health Insurance Ombudsman (02)