The Insurance Process
Hafez Atweh
Provider Relations Manager
Agenda
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Corporate Agreement.
Membership.
Hospital Agreement & Process.
Pre-authorization of Service.
Billing of Claims.
BUPA Internal Processing.
Reconciliation of Accounts.
BUPA World Wide
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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
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Operating in Saudi Arabia for 8 years
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14% Market Share with clients including NCB, Samba, Savola
Makshaff, Proctor & Gamble….etc
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Nationwide hospital & clinic network
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All services and insurance provided in the Kingdom
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Operation Center in Jeddah, Sales & Service in Riyadh and
Khobar
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Employs more than 125 Healthcare Professionals
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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.
Visibility of Health Issues
Data
Available
Occupational
Health
Litigation
Known Issues
& Cost
PMI
Ill-Health
Retirements
Sickness Absence
No Data
Available
Occupational
Overweight
Risks
Raised Cholesterol
High Alcohol
Usage
Smokers
Diet
Unknown
Issues & Cost
Raised Blood
Pressure
Sedentary
Lifestyle
Stress
Present But Not
Reported,
Corporate
Hospitals
Insurance Co.
Patients
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:
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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
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Hospitals & Polyclinics Network through out the Kingdom
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Packaged pricing with written contract for Value & Control
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Prompt payment settlement with providers
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Standards - ICD10 coding
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Educational and training workshops
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Usage of quality accreditation standards
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Direct settlement.
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Unit cost and frequency monitor and control.
Pre-authorization of Services:
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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:
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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.
In/Out-patient Claims
Total Incidence
(by Volume)
Total Incidence
(by Value)
3.0%
30.0%
97.0%
70.0%
In-Patient
Out-Patient
Claims Frequency - By Value
1200
1000
No. of Claimants
800
600
400
200
0
0-100
100200
200300
300400
400500
500- 1000- 5000- 10K1000 5000 10000 15K
15K20K
Value of Claims (SR)
20K25K
25K30K
30K35K
35K40K
40K45K
45K- >50K
50K
Clinical Coding
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Standardized coding used - ICD 10
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Measurement means management
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Management means standards and comparison
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Performance means Quality of care and Cost effectiveness of care
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Coding means consistent identification of Doctors and hospitals
matched to resources used .
Hysterectomy Abdominal Q0740
Hysterectomy and removal of adnexae Q0780
Day 4
no cannulae / lines / catheters
mobile
full diet
Discharge Criteria Day 5
All 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)
7.0
6.0
Actual
5.0
4.0
3.0
2.0
1.0
0.0
0.0
1.0
2.0
3.0
4.0
Expected
5.0
6.0
7.0
Length of Stay Distribution
W3710 - Total prosthetic replacement of hip joint
Consultant Y
700
18
16
600
14
Number of Episodes
500
12
400
10
300
8
6
200
4
100
2
0
0
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Length of Stay
Consultant
BUPA
21
22
23
24
25
26
27
Breakdown of Medical Cases
By Value
By Volume
23.3%
37.7%
25.7%
29.0%
0.9%
5.9%
6.2%
6.1%
7.2%
7.6%
6.2%
11.3%
15.2%
3.6%
9.4%
Respiratory system
Digestive system
Ear & Mastoid process
Examinations (incl. pre-employment)
Skin & Subcutaneous tissue
Abnormal clinical & lab findings
Pregnancy, Childbirth & the Puerperium
Others
4.6%
Hospital Usage
2.5%
4.5%
2.4%
6.4%
52.8%
15.5%
15.9%
Olaya Medical Center - Riyadh
Almana General Hospital - Dammam
Dr S Fakeeh Jeddah
Almana General Hospital - Khobar
Bugshan General Hospital - Jeddah
Others
Dr. Ahmed A. Daghastani Hosp. - Jeddah
Medical Costs - By Value
Claims Value
Reason for Partial
Payment
13.7%
19.4%
45.6%
25.8%
80.6%
Paid in Full
Not Fully Paid
14.9%
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
Payment
Input Claims
Customer Service - BUPA process
Dedicated Customer Service call centre
Our Customer Service team uses worldclass call centre to answer all your queries
Our dedicated
Customer Service lines
HOTLINE
02 663 0505
TOLL FREE
800 244 0307
Ready
Emergency
to serve you - contact numbers
Saturday to
available after
Thursday - 8AM normal working
to 9PM
time
Thank you, Questions please