The Insurance Process

Hafez Atweh

Provider Relations Manager

Agenda

• Corporate Agreement.

• Membership.

• Hospital Agreement & Process.

• Pre-authorization of Service.

• Billing of Claims.

• BUPA Internal Processing.

• Reconciliation of Accounts.

BUPA World Wide

• BUPA is a leading independent provider of health services:

– SR 12.8 billion Turnover

– Over 5 million members worldwide

– Professional service to members and corporate management

based on over 50 years of business experience

– Ownership and management of over 600 facilities, including

Hospitals, care homes, screening centers, close care

retirement housing and health clubs

– Employs more then 40,000 healthcare professionals

– Leader in managed care in Australia, Spain and UK

BUPA Middle East

• Operating in Saudi Arabia for 8 years

• 14% Market Share with clients including NCB, Samba, Savola

Makshaff, Proctor & Gamble….etc

• Nationwide hospital & clinic network

• All services and insurance provided in the Kingdom

• Operation Center in Jeddah, Sales & Service in Riyadh and

Khobar

• Employs more than 125 Healthcare Professionals

• Tailored Service system to meet Customer’s needs

Mission

To “Take care of the lives in our hands” as we

provide a trusted and professional healthcare

insurance service to customers,hospitals and

clinics in the Kingdom.

Insurance Definition:

•A contract that provides compensation for specific losses in exchange for a periodic payment. An individual contract is known as an insurance policy, and the periodic payment is known as an insurance premium.

•A formal social device for reducing risk by transferring the risks of several individual entities to an insurer. The insurer agrees, for a consideration, to pay for the loss in the amount specified in the contract.

Sickness Absence

Occupational RisksOverweight

High AlcoholUsage Smokers

Raised CholesterolRaised Blood

Pressure

StressSedentaryLifestyle

DataAvailable

No DataAvailable

Known Issues& Cost

Unknown Issues & Cost

Present But Not Reported,

Measured or Costed

Diet

PMIIll-HealthRetirements

Occupational

HealthLitigation

Visibility of Health Issues

Patients

Insurance Co.

CorporateHospitals

The Employer Needs:

- Value for money.

- Administration taken away.

- Control over cost.

- Healthcare partner.

- Professionalism.

- Improve performance by maximizing the people contribution.

The Employee Needs:

- Accredited healthcare providers.

- Improved customer services.

- Better and more appropriate care.

- Consistency and assurance.

- Support when needed.

- Care and prompt access to providers.

The Healthcare Providers Need:

- Large number of patients.

- Provide wide range of treatments.

- Paid promptly for the services provided.

- Good working relationships.

- Good understanding of the benefits.

- Resolve issues quickly.

Corporate Process:

• Customer “ With a Need “.

• Agree benefits and exclusions.

• Agree Premiums.

• Sign Agreement.

• Notify providers.

• Issue membership cards.

• Distribute Information Pack.

• Start provision of services.

Membership Cards:

Hospital Network

Hospitals & Polyclinics Network through out the Kingdom

Packaged pricing with written contract for Value & Control

Prompt payment settlement with providers

Standards - ICD10 coding

Educational and training workshops

Usage of quality accreditation standards

Direct settlement.

Unit cost and frequency monitor and control.

Pre-authorization of Services:

• Outpatient services in excess of SR1000.

• Inpatient Admissions.

• Day case services.

• Emergency services within 24 hours.

• MRI & CT-scan.

• Dental, Optical, and Maternity.

Monthly Claim Requirement:

• Complete forms.

• Eligible members.

• Medical report.

• Original invoices

• Discount & Deductible collected.

• Results of Lab & Rad. Investigations.

• Group Summary

• General Summary.

Discount & deductible on statement

Discount &

deductible on invoice

Patient’s Contribution – Deductible:

1- Fixed Amount: SR20, SR10

2- Percentage: 10% O/P (Outpatient)

3- Nil.

Deductible Should Be Collected From Net Amount Not From Gross.

Total Incidence(by Volume)

3.0%

97.0%

In-Patient Out-Patient

In/Out-patient Claims

Total Incidence(by Value)

30.0%

70.0%

0

200

400

600

800

1000

1200

0-100 100-200

200-300

300-400

400-500

500-1000

1000-5000

5000-10000

10K-15K

15K-20K

20K-25K

25K-30K

30K-35K

35K-40K

40K-45K

45K-50K

>50K

Value of Claims (SR)

No.

of

Cla

iman

ts

Claims Frequency - By Value

Clinical Coding

• Standardized coding used - ICD 10

• Measurement means management

• Management means standards and comparison

• Performance means Quality of care and Cost effectiveness of care

• Coding means consistent identification of Doctors and hospitals

matched to resources used .

Hysterectomy Abdominal Q0740Hysterectomy and removal of adnexae Q0780

Day 4 no cannulae / lines / cathetersmobilefull diet

Discharge Criteria Day 5All symptoms controlled by oral medication Baseline, BP, pulse and temperature( without antipyretics) Normal diet for 24 hours Passing urine and bowel movements for 12 hours Balance of care lies with nursing staff/ care could be given safely in alternate place of service ADL and needs can be met with or without assistance Patient has received instruction /education and follow up planning

Average LOS for Selected Doctors at Hospital X

Surgical Inpatient Episodes (Aug 99 - Sep20)

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0

Expected

Act

ual

Length of Stay Distribution

Consultant BUPA

W3710 - Total prosthetic replacement of hip joint

0

100

200

300

400

500

600

700

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

Length of Stay

Nu

mb

er

of

Ep

iso

de

s

0

2

4

6

8

10

12

14

16

18Consultant Y

By Volume

6.1%

0.9%

23.3%

5.9%

7.2%7.6%

11.3%

37.7%

Respiratory system Digestive system

Ear & Mastoid process Examinations (incl. pre-employment)

Skin & Subcutaneous tissue Abnormal clinical & lab findings

Pregnancy, Childbirth & the Puerperium Others

By Value

6.2%

25.7%29.0%

6.2%3.6% 9.4% 4.6%

15.2%

Breakdown of Medical Cases

6.4%

52.8%

15.5%

15.9%

2.4%2.5%

4.5%

Olaya Medical Center - Riyadh Dr S Fakeeh Jeddah

Almana General Hospital - Dammam Almana General Hospital - Khobar

Bugshan General Hospital - Jeddah Dr. Ahmed A. Daghastani Hosp. - Jeddah

Others

Hospital Usage

Claims Value

80.6%

19.4%

Paid in Full Not Fully Paid

Medical Costs - By Value

Reason for Partial Payment

14.9%

13.7%

25.8%

45.6%

Ineligible item

Inappropriate treatment

Non-compliance with contract

Others

BUPA Claims Process:

Provider

CCU

E-claim

Upload Claims

System Adjudication

Medical Adjudication

Technical & Medical QA

Statement

Input Claims

Payment

Customer Service - BUPA process

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Emergency contact numbers

available after normal working

time

Thank you, Questions please