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HEALTH INSURANCE

By

Rahul Sharma

Fellow With Insurance Institute Of India

MBA-Health managementMSc Computer Science

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Topic To be Covered

1. Review

2. Underwriting In Health Insurance

3. Claims Management

4. Provider Contracting

5. Payment Mechanisms

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Review

What is risk?

What is peril?

What is Insurance?

What is health?

What is health Insurance?

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Claims Management

“Claim is a set of unique transaction that is

done by the policy holder , against the policythat is issued to him/her.” 

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Types Of Claims

1. Cashless

2. Reimbursement

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Advantages Of Cashless

Cashless is a very good facility for patients asthey don’t need to pay money at the time of 

treatment to the hospital

Patients do not need to run after the insurancecompany/TPA for the payment.

Easy and hassle free as they do not need tokeep any papers of the claims.

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Disadvantages

Patient has to wait till there is no approval formthe TPA/Insurance Company.

As far as hospitals are concern they need to

maintain all the documents related to theclaims of the patients .

Hospitals do not get payment at the time of thetreatment, they need to wait for 21 days to get

the payments.

There are a chance that the bill may be inflatedby the hospital results in exhausting the sum of

the patient

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Advantages Of Reimbursement

Hospital get the payment directly form thepatients.

Hospital do not need to maintains the claim

papers of the patients.

For patient , there are less chance that the billof the patient will be inflated unnecessarily.

Patient Do not need to wait for the approvalform the TPA/Insurance Company.

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Disadvantages

Patients need to maintain all the paper of theclaims

Patients have to follow up with the insurance

company/TPA for payment.

Sometimes because of the lack of knowledge ,patients suffers as they do not have proper

documents.

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Claim Management

Claims MIS

Payment MIS

Claim ratio

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Claim MIS

Month

Date Of Intimation

Transition Id

District

Claim No

Policy No

Hospital Name

Location

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Claim MIS

NOP

HOF

DOA

Package Selected Claimed Amount

Approved Amount

Balance Amount

Final Liability

Float No

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Types Of Claims MIS

Hospital wise Claim MIS

Disease Wise Claim MIS

Policy Wise Claim MIS

District Wise Claims MIS

Daily MIS

Weekly MIS

Monthly MIS

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Claim/Policy Usages Ratio

What is the Claim Ratio

How to calculate claim Ratio

Policy usages Ratio

How To Calculate Policy usages Ratio

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Provider Contracting

What do you mean by service provider inHealth Insurance.

Role Of the Service Providers.

Criteria to select the service Providers.

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Service providers

Hospitals

Day care Centers

Diagnostic Centers

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Criteria To select A hospital

Differ from Insurance company to Insurancecompany, from policy to policy.

Min 6-10 Beaded.

For surgery Min OT, ICU, lab.

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Roles Of the Service Provider

To provide the treatment to the policy holdersas per T&C of the policy.

Maintain the claims documents of the patients.

Maintain the minimum requirement to beempanelled.

Follow the policy T&C ethically.

Proper and continuous reporting toTPA/Insurance company in desired format.

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Issues With Services providers

Ethical Issues

Proper Reporting Issues

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Payment Mechanisms

Claim Intimation

Claim Processes

Claim settled/rejected

Float Raise

Cheque Dispatched/ Online payment

Follow up with the hospital for the confirmation

Dispatching/ mailing a letter with the details ofthe settled claims.

Dispatching the rejection letter to the hospital

with proper stamp and sign to the hospital with

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Float

Float is a set of settled claims done by policyholder against their policy.

Every Float contain a unique no.

Every Float includes all the details of thehospitals including bank details and PAN cardno and also all the relevant details of the

patients.

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Thank You