Paying Claims 6

8/3/2019 Paying Claims 6

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Paying ClaimsPaying ClaimsChapterChapter -- 66


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Paying ClaimsPaying Claims

Claim AssessmentClaim Assessment

Direct SettlementDirect Settlement

Electronic Data InterchangeElectronic Data InterchangeClaim FormsClaim Forms

Payment DeterminationPayment Determination

Notification to the memberNotification to the memberUse of Procedure CodesUse of Procedure Codes


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Controlling Claims CostsControlling Claims Costs

Health Cash Plan ClaimsHealth Cash Plan Claims

Dental claimsDental claims


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How to avoid Lengthy AdministrativeHow to avoid Lengthy AdministrativeProcedure for claims ?Procedure for claims ?

PrePre--authorizationauthorization Referral required from GPReferral required from GP(Declaration from consultant for further treatment(Declaration from consultant for further treatment--Claim form submitted before treatment),Claim form submitted before treatment),

Payment ExclusionPayment Exclusion Without insurer Prior consentWithout insurer Prior consent..


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Submission of a Claim Form after treatment.Submission of a Claim Form after treatment.

GP Signed Claim formGP Signed Claim form -- Original bills.Original bills.

Signed Group Scheme Claim Form beforeSigned Group Scheme Claim Form before

treatmenttreatment Co. Secretary.Co. Secretary.


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Claims AssessmentClaims Assessment

Claims ProcessClaims Process Outsourcing / Co. Staff.Outsourcing / Co. Staff.

Acceptable Medical outcome for InsurerAcceptable Medical outcome for Insurer

(Claim process Decision ) :(Claim process Decision ) :Less Expensive,Less Expensive,

Less Invasive (Troublesome) &,Less Invasive (Troublesome) &,

Alternative Treatment.Alternative Treatment.


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Claims AssessmentClaims Assessment

How to achieve easy approach to ClaimHow to achieve easy approach to Claim

Process :Process :

PrePre -- authorisationauthorisation Insurer consult beforeInsurer consult beforetreatment,treatment,

Case ManagementCase Management Medically qualified staffMedically qualified staff

(Manage Claims Costs(Manage Claims Costs StandardStandardprocedures).procedures).


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ContractContract Patient , Hospitals / Specialist.Patient , Hospitals / Specialist.

Change in the Nature of Claim Processing.Change in the Nature of Claim Processing.

PMI InsurerPMI Insurer Pricing Agreements with Pvt. &Pricing Agreements with Pvt. &NHS Hospitals (Monthly basis).NHS Hospitals (Monthly basis).

Direct SettlementDirect Settlement -- PMI Insurer (Bills ofPMI Insurer (Bills of

Medical Treatment / Services).Medical Treatment / Services).


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Advantages :Advantages :

Payment ArrangementPayment Arrangement Customer need notCustomer need notto worry,to worry,

All Hospital Costs with in band entitlementAll Hospital Costs with in band entitlementare coveredare covered Customer,Customer,

Guaranteed PaymentGuaranteed Payment Hospitals (WithoutHospitals (Without

delay),delay),Premium Competitiveness / ImprovePremium Competitiveness / Improve

profitabilityprofitability Insurer.Insurer.


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Direct Settlement with SpecialistsDirect Settlement with Specialists Difficulties:Difficulties:Attitude of Medical Professionals towardsAttitude of Medical Professionals towards

Healthcare Insurer,Healthcare Insurer, Large number of SpecialistsLarge number of Specialists Administrative taskAdministrative task

for insurer.for insurer.PMI InsurerPMI Insurer Weekly , Fortnightly / MonthlyWeekly , Fortnightly / Monthly

Settlement.Settlement.


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Electronic Data InterchangeElectronic Data Interchange(EDI)(EDI)

Computerised Claims Data EntryComputerised Claims Data Entry ReducedReduced

many Claim Processing Problem & Costs.many Claim Processing Problem & Costs.

Specialists & HospitalsSpecialists & Hospitals -- Easy, Quick.Easy, Quick.Advantages ofEDI :Advantages ofEDI :

Quick Process,Quick Process,

Improve Data qualityImprove Data quality Data checks, &Data checks, &Elimination of Paperwork.Elimination of Paperwork.


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Electronic Data InterchangeElectronic Data Interchange(EDI)(EDI)

EDIEDI Popular, Cost effective, Data Reliability,Popular, Cost effective, Data Reliability,

Data Sharing, Processing of Large & ComplexData Sharing, Processing of Large & Complex

Claims & Internet based services to Patient,Claims & Internet based services to Patient,Hospitals Specialists.Hospitals Specialists.


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Claim FormsClaim Forms

Claim form contain information :Claim form contain information :

Customer & the Claimant IdentificationCustomer & the Claimant Identification

Spouse,Spouse,Nature of the Condition for Treatment,Nature of the Condition for Treatment,

Dates of the Treatment,Dates of the Treatment,

Member Declaration StatementMember Declaration Statement TreatmentTreatmentReceived (Claim).Received (Claim).


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Company Paid Scheme :Company Paid Scheme :

Customer & the Claimant IdentificationCustomer & the Claimant Identification

Spouse,Spouse,Nature of the Condition for Treatment,Nature of the Condition for Treatment,

Dates of the Treatment,Dates of the Treatment,

Member Declaration StatementMember Declaration Statement TreatmentTreatmentReceived (Claim).Received (Claim).

ConfirmationConfirmation Treatment Entitlement.Treatment Entitlement.


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After Observing Claim form FurtherAfter Observing Claim form Further

assessment is done for Benefits.assessment is done for Benefits.

Premium Payment,Premium Payment,Original BillsOriginal Bills No Photocopies,No Photocopies,

Member Entitlement for benefits,Member Entitlement for benefits,

Previous Claim historyPrevious Claim history Maximum AnnualMaximum AnnualBenefits,Benefits,


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Further Investigation (RecognisedFurther Investigation (RecognisedSpecialist)Specialist) If necessary.If necessary.

Recognised Specialist :Recognised Specialist :A person having knowledge & ExpertiseA person having knowledge & Expertise

relevant to the Injury or illness to whichrelevant to the Injury or illness to which

treatment relates.treatment relates.


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Eligibility ChecksEligibility Checks

Premium PaymentPremium Payment Treatment,Treatment,

Maximum Claimed treatment Annual limit,Maximum Claimed treatment Annual limit,ExclusionsExclusions Policy terms,Policy terms,

Patient cover by the Policy,Patient cover by the Policy,

Conditions of the Policy,Conditions of the Policy,

NonNon DisclosureDisclosure Policy Cancellation,Policy Cancellation,

Hospital / SpecialistHospital / Specialist Recognised.Recognised.


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Payment DeterminationPayment Determination

Payment DeterminationPayment Determination after claim validity.after claim validity.

PersonPerson receive amount,receive amount,

Amount of Payment .Amount of Payment .


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Notification to the MemberNotification to the Member

Confirmation Note (Customer)Confirmation Note (Customer) Full ClaimFull Claimpayment to Medical Service Provider.payment to Medical Service Provider.

Partial Claim SettlementPartial Claim Settlement OutstandingOutstandingamount (Remittance advice, Notification toamount (Remittance advice, Notification tothe member).the member).

Outstanding amountOutstanding amount Member to Provider.Member to Provider.


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Use of Procedure CodesUse of Procedure Codes

Early stages Claim ProcessingEarly stages Claim Processing ImpairmentImpairment& Surgical Procedures' Descriptions.& Surgical Procedures' Descriptions.

Problem in severity Identification.Problem in severity Identification.Codification of Impairment, SurgicalCodification of Impairment, Surgical

Procedure, & Treatment.Procedure, & Treatment. -- Quick ClaimQuick ClaimAssessment (Frequency & Treatment).Assessment (Frequency & Treatment).

Computerised Claims processing systemComputerised Claims processing system Helpful in accurate Claim Assessment.Helpful in accurate Claim Assessment.


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Use of Procedure CodesUse of Procedure Codes

Standards of ImpairmentsStandards of Impairments WHOWHOImpairment classification.Impairment classification.

Surgical & Medical procedures CodesSurgical & Medical procedures Codes(Different Codes)(Different Codes) Office of Population,Office of Population,Censuses & Surveys (OPCS) / Office forCensuses & Surveys (OPCS) / Office forNational Statistics (ONS).National Statistics (ONS).


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Medical Inflation CostMedical Inflation Cost Premium Increase.Premium Increase.

The increase year on year in the cost ofThe increase year on year in the cost of

delivering medical expenses.delivering medical expenses.

Why Medical Inflation is higher than RPI ?Why Medical Inflation is higher than RPI ?

Advance Technology,Advance Technology,

Newly Developed Medical Procedures,Newly Developed Medical Procedures,

More Complex Medical Procedures, &More Complex Medical Procedures, &

Rising Demand for treatment.Rising Demand for treatment.


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Pricing Agreement with Hospital (Annually)Pricing Agreement with Hospital (Annually)Package deals,Package deals,

Day Case Surgery (No over night stay)Day Case Surgery (No over night stay) Incentive for Patient & Specialists,Incentive for Patient & Specialists,

Clinical Guidelines (Protocols)Clinical Guidelines (Protocols) InsurerInsureremploy Medical Professionals, Clinical Normsemploy Medical Professionals, Clinical Norms(Medical advisory board, Clinical Consensus(Medical advisory board, Clinical ConsensusPanels), Data Sharing (Insurer & Hospitals),Panels), Data Sharing (Insurer & Hospitals),


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Managed Care (Originated from USA)Managed Care (Originated from USA) Obligatory PreObligatory Pre approval procedure,approval procedure,Control & Influence on MedicalControl & Influence on Medical

Professionals, Help lines avoid surgery, UseProfessionals, Help lines avoid surgery, Useof particular hospitals, Second opinions fromof particular hospitals, Second opinions fromspecialists, amount limits for treatment,specialists, amount limits for treatment,Home Nursing, Employment of MedicalHome Nursing, Employment of Medical

Specialist on a Session Basis (Notional HalfSpecialist on a Session Basis (Notional Halfdayday Part / Full time for a specified numberPart / Full time for a specified numberof days).of days).


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Four Forms ofHealth Cash Plans :Four Forms ofHealth Cash Plans :

Small Value High Frequency ClaimsSmall Value High Frequency Claims Payment after claim form & OriginalPayment after claim form & Originalreceipt for treatment cost, Claimreceipt for treatment cost, ClaimValidity (Through automation), SampleValidity (Through automation), Sampleclaims (Fraud detection),claims (Fraud detection),

Claims Where treatment is carried outClaims Where treatment is carried outby a known Providerby a known Provider Payment directPayment directto Service suppliers,to Service suppliers,


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Higher Value ClaimsHigher Value Claims Greater Checks areGreater Checks areapplied,applied,

Third Party ClaimsThird Party Claims P . A cover, FuneralP . A cover, Funeralgrant (Claims wholly / partly handled bygrant (Claims wholly / partly handled bythird party).third party).


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Dental ClaimsDental Claims

Procedures of claim payment :Procedures of claim payment :

Health Cash plansHealth Cash plans -- Small Value HighSmall Value HighFrequency Claims , Higher Value Claims,Frequency Claims , Higher Value Claims,

Treatment is carried out by a knownTreatment is carried out by a knownProvider, Third Party Claims,Provider, Third Party Claims,

Dental InsuranceDental Insurance Dentist original receiptDentist original receipt,,

Capitation PlanCapitation Plan No Claim Requirement, Dentist &No Claim Requirement, Dentist &patient complete a Claim form for authorisation.patient complete a Claim form for authorisation.


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The EndThe End

Documents

Paying Claims 6