What is the most common problem you face with your health insurance provider? How do you think this problem can be resolved?

Coverage and claims - this can be solved by sending out complete guidelines to the customer on what are the coverages and limitations to the insurance. 

Documentation of Medical Records.... I believe EMR is best solution if properly implemented.

Insured's age & sickness

solution is get the full medical report & included the extra premium   

Thank you Brother for asking me this question. Actually there can be a lot of problems with the health insurance providers / policies. Most common are as follows:

1) Customer Services

2) Claims Authorization

3) Claims processing time

and many more.

With my humble experience with ADNOC Group of companies, what we did is that we connected their level of services with yearly renewal contracts. If their services are not up to the mark, we'll dis-qualify them for bidding in the next  year's contract. After introducing this and having very strict check and balance, we were able to notice drastic changes in the level of their services provided to our employees and dependents. This can be explained more if you specifically ask what you exactly want to know. Hope, I have somewhat answers your query.

Hamdan 

FIRST, there is lack of clarity in the question,

It is addressed to whom?

To the customers?

To the insurance co managers?

To the providers?

 

Let me analyze from these three angles ,

 

From the customer's point of view:

 

The customer [patient] faces the provider face to face, so the provider is at his good will serving his needs,

 

The waiting time for approval is the main concern for the customers , yesterday one patient with TROPONIN +ve waited for 2 hours for hospital admission , golden hour is 90 minutes after the symptoms where a definite treatment must be initiated .

 

APPROVAL SHOULD BE INSTANT AND IMMEDIATE IN CARING CRITICAL ILL PATIENTS

 

HOW TO DO IT?

 

INSURERS SHOULD HAVE PRIORITY BASED SPECIFIC PROTOCOLS,

 

INSURERS should use effective tools to interact with their customers often and also when needed , here BUPA is trying by using interactive messages and sms , other companies may follow soon ,

 

To my knowledge customers don’t have serious issues with their providers , if any it is effectively mediated by the provider's insurance dept ,

 

Issues with INSURERS [health insurance companies] in Saudi setup,

 

Many insurance companies here issues low premium policies, it is known as IQAMA INSURANCE [NATIONAL ID], in Saudi, active insurance card is mandatory to renew the national id,

 

When the contract is signed, the provider is asked to maintain low average cost and low member per cost less than 100 SR,

 

This constrictive compulsion from the insurer directly affecting the QUALITY of the health care provided to his clients.

 

As a cost cutting measure insurance companies employ non-medical graduates who has insurance course certifications , for them every service given by the provider is excessive and they don’t hesitate to deduct them,

 

The insurer practices many kinds of discounts, service fees and deductions, which leads to inferior quality of services and financial loses to the providers,

 

I met with many insurance corporate managers , most of them are non-medical MBAs , they talk about cost cutting , targets, more financial gains and less willingness to spend on quality oriented health services to their clients ,

They are very much tempted to talk about doctors, about medical science, about excessive services prescribed by the physicians, most of the time I am pissed off belong a medic.

 

Like this, many many issues are there.

 

 

Issues with PROVIDERS in Saudi setup,

 

A doctor can specify 4 ICD codes for a single complaints and ask for many investigations, this is  because the doctors are pushed from the management indirectly luring them with commission 

        

    

 

Duplicate receipt is another issue, which is done deliberately or not, has to be contained,

 

Lengthy hospital stays to bill the insurer X into multiples,

 

Patient visiting many providers utilizes services and medications, which may adversely affect his own health,

 

EXCESSIVE services and medications – many providers does this, incurring more financial liability for the insurer.

 

SOLUTION:

 

1 - PERIODICALLY REACH TO THE PROVIDERS, MEET WITH DOCTORS, SHARE KNOWLEDGE ON INSURANCE FACTS AND EMPHASIS ON ETHICAL EVIDENCE BASED MEDICAL PRACTICE  

 

2 – EMPLOY MORE MEDICAL PROFESSIONALS  TO OVER SEE CLAIM AUDITING AND FIND OUT FRAUDULENT UNETHICAL MEDICAL PRACTICES AND NOTIFY THE PROVIDER FOR NECESSARY POSITIVE REMEDY , IF THE PROVIDER FAILS TO COMPLY WITH THEN TAKE THE ISSUE TO THE GOVERNING BODY-CCHI ,

 

3- IF POSSIBLE BRING ALL THE PROVIDERS UNDER ONE ROOF THROUGH CLOUD BASED LIVE MONITORING , THIS MAY NEED A ELECTRONIC CHIP BASED CARD .

 

 

4- GO FOR E-CLAIMS AND SUBMISSIONS and USE A EFFECTIVE SOFTWARE TO FIND OUT EXCESSIVE SERVICES, EXCESSIVE MEDICATION, DUPLICATE CLAIMS AND FRAUDS. 

The most problem which every insured faces in Health insurance is the claim settlement, to resolve it the insurers should encourage cashless facilities.

if u r asking me as a bayer, the most common problem is the overservices requests, the non-justified requests.

while as a customer, the delay in getting approvals, which is a circle between the payer & provider.

Sorry my friend but your question is not clear , so I will answer it the way I understand it. If you means what is the common problem between the Care provider and the patient, I think that is the over fees and the unnecessary health care procedures especially in the urgent cases due to the lack of experience or greedy, to solve or reduce those problems the insurance company must make a contract with the provider contains many things to order the prices ....etc , and it must have pre-approval center full with skilled doctors and at last it must have will trained and expert auditors . But if you mean the problem to the patient I think that is the delay of taking acceptance or rejection (TAT) , this is mainly due to lack of experience of the provider employee or pre-approval center employee, human error ...etc. I think that regular training will reduce this problem.

Some insurance companies cover certain test and some don't this causes problems with test in the medical facilities and prolongs your diagnosis. Why is this a common problem. Why don't insurance companies cover all tests if you are paying for coverage why the hassell. As much as insurance cost everything should be covered.

It is easy to manage health insurance and reimbursement process electronically, but the most problems that can rise now and then with in the contract constraints is supply induce demand, the health care providers provide more unnecessary health care to the insurer, because the payment process gives an incetives to the provider to provide more health care (in case of fee for services) there for other payment mechanism should be deployed to share the risk between the insurance company and the health care providers, another thing the cost of health care services for pricing purposes, Many insurance company accept prices by just bargain without any evidence, Insurance company may lost a lot, there for costing for provider payment should take place first and both insurance company and provider agreed on bench mark cost and bargain for the profit, thus no lost for both

No doubt the complete time taken to settle the reimbursement claims for approval/rejection is the most common problem from health insurance providers. This time is called as TAT(Turn Around Time). The best way to reduce the TAT is to provide cashless facility in as many hospitals as possible. More number of cashless claims will be increased, hence automatically number of reimbursement claims will be reduced. Again the reduced number of reimbursement claims will enable to close the cases faster. Dr Asad Syed +919923311369