Claims System Overview

Transcription

1 Claims System Overview 1

2 The Problem 2 Insurers cannot deliver a profitable Group Health business and yet carry all the risk. Over-payment of claims vs. underwriting rules Member identity fraud Claims inflation at provider level Over-utilization of policy benefits Excessive cost around member and policy administration Claims not properly adjudicated from point of treatment, largely manual processes Wholesale inefficiencies throughout the value-chain, adds high cost Members (inc. HR) -> Provider -> Agent -> Insurer

3 The Lost Ratios are out of control 3 Most insurers continue to offer health insurance at an overall loss to protect high profit lines e.g. Life Insurance Premiums are increasing at over 20% per annum to cover increasing health and administration costs Administration costs are factoring as a high % of premium usually > 30% - especially with TPA s Products are becoming generic by insurer driving price rather than value based competition Provider over-servicing and over utilisation of cover causing dramatic increases in claims costs Outsourcing to TPA s eliminates effective risk management and control from the insurer

4 Solve the universal claim problems with Omni 4 Omni embeds the underwriting and policy rules into the claims adjudication engine for immediate use at claim time Omni manages the process from pre-approval to claim payment in a single workflow without re-entry of data Omni Auto-adjudicates >95% of claims Omni Utilises API driven interfaces to talk to other systems e.g. Hospital Management Systems Omni Mobility allows for member / provider / group HR entry removing heavy claims admin overheads Omni captures all elements of claim risk at admission and reduces latent exposure to over utilised benefits and non-payable charges

5 Control the TPA 5 Omni allows opex based administration functions to be outsourced to the TPA Omni allows the insurer to give TPA access to the automation & complexities of the claim system via the internet or mobililty Omni allows the Insurer to manage risk in real-time Omni ensures that transactions are real-time and data is not mismanaged as it is passed from point to point Get everyone on the same platform, in source RISK again

6 The Claim Types Supported 6 Prior Approval Primary Care (Outpatient) Hospital (Inpatient) Travel Non-medical Risk (TPD, Life, Trauma) Omni Adjudication Engine

7 An Intelligent Rules Based Adjudicator 7 Omni uses an intelligent rules-engine: Identify all policy and underwriting Identify all product and benefit limits Make all pass & fail decisions No human intervention or product knowledge required Members, providers, TPA s, HR can enter claims without the need to understand product complexities Over 100 pre-defined rules pre-configured for immediate use

8 The Benefits 8 Complex claims adjudicate in real-time, sub-second Greater than 95% of all claims will pass through the adjudication engine without any need for operator intervention Omni allows for work-flow based authorisation controls allowing claims to adjudicate and pass for payment or await authorisation by higher user security clearances Individual claim lines can be pre-released while the balance of the claim is administered e.g. Paying Specialists before hospitals Claims can be paid real-time, or in batch

9 Operate claims with fewer staff, more accurately 9 Operate with as few as 10% concurrent staff numbers Electronic rules adjudication as many as 40 adjudication checks will be undertaken on each claim line claims - sub-second 95% of claims are adjudicated without human intervention Self service options allowing providers, groups and members to enter their own claims and have them adjudicated in real time Benefit limits & utilisation of benefits are on-line to the adjudication engine to ensure true risk is managed Market Observation Omni 1 administrator per 1,000 members insured 1 per administrator per 10,000+ members insured

10 The Product Configurator 10 Build complex products in minutes Apply rules to benefits Configure for clients or template and model For the users, no programming Use these rules with the claims adjudicator in real-time

11 Add Multiple Rules per Benefit Line for Adjudication 11

12 The Adjudicator adjudication Result 12 Adjudication by click of a button by anyone no decisions to make. A multitude of checks as many as 40 per claim line sub second Adjudicate whole claim or individual claim lines for immediate release Adjudication results displayable (as below)

13 A Secure and Controlled Process 13

14 Claims Approval Control 14

15 Users Configure for role, edit options & Group access 15

16 Users Configure for role, edit options & Group access 16

17 Users Configure for role, edit options & Group access 17

18 Claim Menu Entry, Types and Uploads 18

19 My Workflow Claims List 19

20 Claim Header 20

21 Claim Lines (n.b. this has been split to reveal in this PTT display) 21

22 Provider Claims 22 Provider Claims Provider Claims A mechanism to connect the providers directly to the Omni administration System by allowing providers to enter claims Risk Managing Provides access to underwriting rules and adjudication engines within Omni Efficiencies Ensures that data is entered once relieving administration overheads Real Time Claims can be monitored in real-time by the insurer TPA Re-positions the role of the TPA and reduces 3 rd party administration cost Unloads administration overheads Designed ideally for In-Network Hospitals and Clinics

23 Provider Claims Entry Authentication 23 Available to providers via mobile devices and the web directly coupled to the Omni backend administration system including the adjudication engine and all risk management features. 3 Factor Authentication of member Card number, photo-id, SMS verification to members phone

24 Provider Claims Entry Declaration 24

25 Provider Claims Entry 25

26 Provider Claims Entry 26

27 Provider Claims Entry 27

28 Control & management with member Mobility 28 Member claims In-network provider identification Claim status Policy & benefit information Two Factor Authentication and photo ID