Accident and Health Insurance Market Overview and Claims Handling Experience in Cambodia. Chea Samnang - ANZIIF (Associate) C.I.

Transcription

1 Accident and Health Insurance Market Overview and Claims Handling Experience in Cambodia Chea Samnang - ANZIIF (Associate) C.I.P 13 March 2015

2 Agenda 1. Market statistics Types of policies available 3. Infinity statistics 4. Claims handling challenges 5. Regulatory environment

3 1. Market Statistics

4 Market Growth - Health GWP $6,877, $4,352,098 $5,313,298 $5,690, $3,339, $1,565, Market statistics

5 Market Growth - Accident GWP $2,840,277 $3,002,880 $3,539, $2,034,453 $2,364, $701, Market statistics

6 Employee Benefits (Health & Accident) Accident & Health Combined: Health & Accident represents only 19.6% of the total general insurance market. What makes it important is that it is the class of business with a high claims frequency GWP $8,693,113 $8,153,575 $6,717,026 $5,373,535 $4,533,706 $10,417,208 How well we handle these claims has a direct impact on how our industry is perceived by the consumer market Market statistics

7 2. Types of policies available

8 1. Inpatient Only these are the most common various plans available covering local employees and are usually referred to as Hospital & Surgical. Various plan options may be selected depending upon the employers budget. Restrictions may also be applied on types of clinics accessible and/or geographical scope. Depending on the employers HR policy, these covers may protect not only the employees but their spouse and dependants. 2. Outpatient normally only provided to corporate customers and either with a small aggregate limit or with an agreed co-payment requirement. These types of policies normally do not cover employee dependants and spouse. 3. In/Out patient including dental and/or optical The most expensive form of cover and only issued in select cases. Whilst in-patient cover is not subject to a co-payment, outpatient, dental and optical need to have realistic copayment requirements. Types of policies available

9 4. Personal Accident capital sum payments only. Some insurers will include a small medical expense benefit payable even if an accident has occurred which is not covered by the capital benefits. In addition it is also noted that some insurers allow medical expenses from illnesses such as food poisoning under the accident policy. 5. Expat Health Many products available to the expatriates living and/or working in Cambodia. Normally in/out patient but including evacuation to out of country health facilities and optional benefits such as dental and optical. Types of policies available

10 3. Infinity market share and claim numbers

11 Infinity Market Share % 49.5% 50.5% Infinity Other 78% Health $6.88M Accident $3.54M ម ទនភ ពជ របស ជនជ ត ខ ម រ

12 Infinity Claim Numbers No ,720 10,354 11,111 12, , , ម ទនភ ពជ របស ជនជ ត ខ ម រ

13 3. Claims handling challenges

14 Claims operational structure Health insurance losses are high frequency, low severity claims which can be broadly identified into 4 basic claim types which a claims operation must manage: 1. Panel clinic (cashless system paying the clinic) Utilising web-based interface technology these reimbursements are normally the simplest to transact provided that there exists a good working relationship with the clinic, and importantly, expectations are clear with a zero tolerance to overtreatment and inappropriate treatment or laboratory testing. 2. Local non-panel (patient pays up-front) Understandably these claims are more time consuming and labour intensive with frequent referral to in-house medical services team required. Exposure to over servicing and overtreatment possible. Claims handling challenges

15 Claims operational structure (cont d) 3. Specialist services (Dental, optical etc) Specialist services particularly dental claims pose challenges to the claims handler. Currently few employers provide this cover to their employees. Dental care in the Kingdom is very poor as this has not been affordable to most Cambodian s. With access to cover you can expect virtually 100% use of available limits. Overtreatment is a challenge but perhaps one of the greatest challenge is unnecessary work and collusion of patients (eg substitution of crown types from say ceramic to zirconium). 4. Out of country There exists a poor perception of the standard of clinics in Cambodia, this leads to a growing number of locals seeking treatment in Vietnam or Thailand. Whilst Thai costs are significantly higher reports are always submitted in English. Reports from Vietnam are submitted in Vietnamese so in-house translation is essential. Claims handling challenges

16 Panel Clinic Selection 1. Shotgun approach or microscope? Desiring to provide your customers with a cashless network of panel clinics is common. How each company approaches this differs. Building a successful network of panel clinics is not just about providing a huge list of panels which will sign a cashless agreement with you in return for the insurer to promote them. How the patient is treated ultimately impacts on how they perceive the insurer so it is important that network partners are carefully selected. Panel clinics need to be geographically spread to reflect your customer base 2. What is the admission rate for the clinic? Clinics with admission rates exceeding 10% may be an indicator of over servicing. Claims handling challenges

17 Panel Clinic Selection (cont d) 3. What diagnostic equipment does the clinic possess? In addition to the ability to perform standard blood, urine and/or stool tests does the clinic have access to x-ray, ultrasound, CT, mammogram or pap smear? 4. What areas of medicine does the clinic specialise in? In addition to general practice does the clinic have qualified specialists such as pediatrics, Eye-nose-throat, diabetes, obstetrics, tropical medicine? 5. Have you monitored patient feedback? What feedback do you receive from patients attending clinics (panel or nonpanel) regarding their perception of treatment and service received? Claims handling challenges

18 Overservicing Over servicing of patients is an issue for all insurers. This is believed to be the single largest contributor to claims leakage. Unfortunately the majority of local patients do not question either the treatment they receive or the necessity of laboratory tests which they are subjected to: 1. Outpatient v Inpatient With the majority of Employee Health Plans being In-Patient covers the temptation for both clinics and patients to admit patients as in-patients for common out-patient conditions to take advantage of insurance is a common occurrence. By monitoring admission rates and diagnosis statistics of individual clinics providing both in/out covers a benchmark admission rate can be derived which will allow the insurer to assess if overservicing due to unnecessary admission exists. Claims handling challenges

19 2. Lab Tests Overservicing (cont d) Patients may present themselves at clinics with common complaints such as pharyngitis, common cold, or diarrhea. Depending on age, duration and severity of symptoms numerous tests may be necessary. However, refer to your in-house medical team for advice to ensure that the tests are warranted. 3. Appropriate medication Naturally the diagnosis provided by the clinic must be consistent with the symptoms disclosed on the claim form. Equally important is that the medication prescribed is appropriate to the diagnosis. This is an important role performed by an insurer s in-house medical expert but a basic understanding of types of drugs (using WHO categories) can alert claims handlers to potential issues. For example why would Diazepam, a WHO category 24 medication for treating anxiety disorders, be provided to a patient suffering from hypertension instead of a category 12 medication which treats hypertension and other cardiovascular conditions? Claims handling challenges

20 Overservicing (cont d) 4. Quantity of medication Once you has been established that the medication is appropriate the claims handler must also be satisfied that the quantity of the medication, particularly take home medication is of an appropriate quantity. For example someone on a course of antibiotics for 5 days should not need to be provided with 30 days supply. Claims handling challenges

21 OTC medications 1. What are OTC s? Over-The Counter medications are drugs that have been found to be safe and appropriate for use without the supervision of a health care professional such as a physician, and they can be purchased by consumers without a prescription. 2. What are Prescription drugs? A prescription drug (also prescription medication or prescription medicine) is a pharmaceutical drug that in most developed countries legally requires a medical prescription to be dispensed so as to avoid potential misuse. Different jurisdictions have different definitions of what constitutes a prescription drug. Claims handling challenges

22 OTC medications (cont d) 3. Availability in Cambodia Both OTC s and Prescription drugs are widely available, the latter without the need for a qualified medical professional s authorisation. 4. Why prescribe OTC s when they can be purchased at a pharmacy? Individual insurers need to identify the difference between OTC and prescribed drugs and determine whether OTC s are insurable and under what circumstances. For example paracetamol given to an in-patient who has just undergone a minor procedure resulting in discomfort or pain should be covered, however if a patient presents at a clinic with a sore throat and headache should throat lozenges and paracetamol be insured? Claims handling challenges

23 What is a Cabinet? Cabinets A cabinet is a medical facility licensed by the MOH which must not: admit a patient for more than 24 hours; Have no more than 2 patient beds; Sell medicines. Why do they exist? Cabinets exist primarily for gainfully employed hospital/clinic doctors to gain additional income. They do this by referring patients to see them outside of their clinic hours or alternatively pay commission to a referring doctor within a licensed clinic or polyclinic. Should insurers support them? With lack of available clinic s in remote provinces patients occasionally go to a cabinet for treatment. How the claims handler deals with this will vary from insurer to insurer. Claims handling challenges

24 Cabinets (cont d) What are the potential risks? Whilst not licensed to sell medicine these establishments sometimes distribute medicines. The danger being that expired medicines discarded by licensed clinics or polyclinics may be distributed by some Cabinets. Over treatment and over servicing is endemic within these establishments. Sourcing of medications is questionable and indeed whether the medications given actually contain what they are supposed is often questioned. Medications may be given without detailed diagnostic tests being conducted Diagnostic tests may be unnecessary and not necessarily conducted under hygienic conditions. Risk of collaboration with patients on invoicing to ensure patient gain. Limited ability to audit records. Claims handling challenges

25 Counterfeit pharmaceuticals What are counterfeit pharmaceuticals? Counterfeit pharmaceuticals or medicines or drugs are fake medicine. It may be contaminated or contain the wrong or even no active ingredient. They could have the right active ingredient but at the wrong dose, usually much less than required so their effectiveness is limited. Counterfeit drugs are illegal and may even be harmful to patients health. How big a problem is it? In Cambodia, a Health Ministry survey conducted in 2002 revealed that 13% of drugs on the domestic market were counterfeit or substandard, including anti-malaria drugs and antibiotics. The World Health Organisation (WHO) estimated in 2014 that 10% 30% of medicines sold in developing countries are counterfeit. No up to date statistics are available for Cambodia however all medications marketed in Cambodia must register with the MoH. Claims handling challenges

26 Counterfeit pharmaceuticals (cont d) What drugs are predominantly counterfeited? Antibiotics, hormones, analgesics, anti-malarial, steroids, and antihistamines are often counterfeited and counterfeits can be grouped into 6 categories: 1. Products without active ingredients; 2. Products with incorrect quantities of active ingredients; 3. Products with wrong ingredients; 4. Products with correct quantities of active ingredients but with fake packaging; 5. Copies of an original product; 6. Products with high levels of impurities and contaminants. How can an insurer know that they are not paying for counterfeit drugs? Without a laboratory analysis it is impossible to tell, only by carefully selecting clinic partners can insurer mitigate this risk. Claims handling challenges

27 Perception of Cambodian health providers There is a perception that the majority of Cambodians have no confidence in the Cambodian managed health care facilities. This stems from various factors: Public sector health is limited; Lack of confidence in doctors qualifications; Lack of experienced specialists; Corruption (cash for treatment means services are provided unfairly); Lack of encouragement from government to motivate people to use local facilities. This creates issues for the claims handler, and is the main reason that patients seek approval to have cover extended to cover treatment in Vietnam and Thailand when often the treatment is available here in Cambodia. Commercially it is good to provide the customer choice however this not only increases claims costs but does not assist in developing an improved perception of local clinics which can provide the same service. Claims handling challenges

28 Claims Handling issues Summary Paying every item invoiced by every clinic and/or cabinet certainly keeps both the customer and the supplier happy. However as an industry we as insurers have a responsibility to ensure that our customers have appropriate treatment at an appropriate cost. Through educating customers and ensuring that suppliers having a clear understanding of an insurers expectations of what constitutes appropriate treatment the standard and perception of health care in Cambodia can improve. Claims handling challenges

29 4. Regulatory Environment

30 1. Ministry of Health The Cambodian Ministry of Health is the government ministry responsible for governing healthcare, the healthcare industry, public health, and healthrelated NGOs within the country. The Ministry governs and regulates the activities of medical professionals, hospitals and clinics in the country. The Ministry maintains 24 provincial health departments and its main offices are located in Phnom Penh. 2. NSSF The National Social Security Fund (NSSF) was established in 2008 for the well-being and protection of employees and workers. At present, it focuses on providing employment injury insurance to workers. It is compulsory for all organisations with more than 8 employees including expatriates. Regulatory Environment

31 2. NSSF (cont d) Cover is restricted to working hours only including journeys to and from home. Maximum cover 1M Riel (US$250). Regulatory Environment

32 ម ទនភ ពជ របស ជនជ ត ខ ម រ