ITIC MENA: Management of medical assistance files and claim costs


John Spears, Vice President of Marketing and Business Development, Global Excel

John’s presentation began by showing the flaws in the historical approach to cost containment, identifying the main problems: “Cost containment used to be retroactive, did not focus on the member or even on the entire the claim, and the fact that success was measured on the basis of a percentage of savings”. “A change is needed,” he continued, “as healthcare inflation continues to outpace consumer inflation, overtreatment has become more prevalent, and cost-to-quality ratios differ significantly from provider to provider. to the other. There is no statistical link between price and quality of care,” he warned participants. It is concerning, he continued, that international suppliers are now looking to the United States for pricing “inspired”. Rising healthcare costs are the biggest challenge for travel insurers, which will see healthcare costs rise in the United States and struggle to increase customer premiums accordingly, John said.

The need for proactive risk management that prevents, mitigates and contains costs is therefore more critical than ever, John said. “Risk management should be performed at all stages of the claims process, should be coordinated with support and case management professionals from start to finish, and should improve the member’s journey.”

John has identified several ways to mitigate cost escalation and prevent and mitigate the risk of high claims costs:

  • Policy Wording: “A policy will cover within reason and necessary costs’
  • Exclusions: for example, if a hospital makes a mistake in patient care
  • Pre-authorization: allows process evaluation
  • Patient support and referral: delivering the right level of care at the right facility, with or without AI-based triage
  • Financial risk management
  • Management of medical records.

Cost containment can take many forms, John said, and insurers need to make sure they have all their bases covered – having direct contracts in key areas with key facilities, negotiating settlements at different levels for different medical claims costs, ensure there are multiple network options (national, regional, etc.) and ensure you are prepared for handling complex claims.

John then shared information on the effect Covid-19 has had on patient care around the world, including delayed diagnosis and treatment of cancer and cardiac treatment, which has led to increased case costs as diseases progress further and require more complex care. , as well as the psychological impact of the pandemic and the effect of the Long Covid.

Dr. Hayder Zubaidy, President and CEO, Occucare Middle East

Dr. Zubaidy began by saying that everyone in the room had the same goals: patient safety and fair costs. He then admitted that in almost every hospital bill there will be “mistakes” which are actually overcharges on the part of the facility. Covid has affected costs in hospitals as it has led to increased overcharging and overcharging, so payers are now taking a closer look at their supplier bills. However, how the process is managed locally is key to managing rising costs.

The Dubai Health System, Dr Z explained, is now working on a Diagnostic Related Groups (DRG) billing process, but this is a relatively new process for the system. The DRG billing process, however, is not applicable to everyone in the market – there will be two different systems for local and international payers – and this is where having a local partner can lead to cost savings. significant costs.

Surviving Covid, for Occucare, has meant changes to the business structure and an increase in international partnerships instead of keeping staff on the payroll in different locations around the world. These partnerships have resulted in cost savings for payers. Partnerships and acquisitions, he said, are the new normal, and they allow companies to operate effectively in a post-Covid world where hospitals may be more likely to charge local providers differently.


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