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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.
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