Business Process Management Health Insurance

Sreevidya Nair Group Lead, Business Systems, Medibank private

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Outline

About Medibank Health insurance in Australia Health insurance benefits paid last year Health industry interaction Business process, business drivers in health insurance Case study and findings Conclusion

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About Medibank

Australias largest private health insurer, incorporating the Medibank private and AHM health funds providing the largest provider network Integrated private health insurance and health service group Across our separate brands almost 3.4 million people are covered Operates over 100 stores and 50 clinics Australia wide Provider of occupational and travel health services to Government and corporate Australia

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Health insurance in Australia

Over 11.7 million Australians are covered by private health insurance Over 10 million Australians with Hospital Cover On 30 June 2010, 44.6% of the population, were covered by hospital treatment cover The most notable increase in coverage during the quarter was for people aged between 30 and 34. Notable decrease in coverage were seen for people aged 20 to 24

Source: http://www.phiac.gov.au/resources/file/quarterlystatisti cs/Qtr%20Stats%20Mar11.pdf

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Health Insurance benefits paid last year

The total benefits paid by private health insurance funds for all types of hospital and general treatment services in the year ending June 2011 was $12.997 billion. Hospital treatment $9.71 billion, General treatment $3.22 billion Benefits paid increased across all category types, with hospital treatment benefits increasing by 8.1% and total benefits increasing by 7.8%.

Source http://www.ahia.org.au/news/stats_and_data/private-health-benefits-paid-by-funds-phiac-june-2011/

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Health industry participants

Hospital Insurance Medicare Clinics Radiology services Pathology services Medical staff

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Interaction

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Business Process within Health insurance industry

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High level business processes within health insurance

Membership People and Culture Medicare transaction

IT

Provider details

Claims entry

Health Insurance Business process

Health care codes and identifiers

Manage Online Services

Claims processing

Sales & Marketing Preventive health

Legal & compliance

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Business drivers for Health insurance

Accurately assessing and pricing risks of insuring a pool of people Securing competitive provider contacts and price Cost effective, technology driven administrative processes Exercising pricing power over small and mid size employers and individuals Getting rid of bad health risks whenever feasible

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Case Study

How a regulatory change in the US changed the Health Insurance and business process

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HIPAA
Health Insurance Portability and Accountability Act of 1996
Title II

Preventing Health Care Fraud and Abuse

Administrative Simplification

Medical Liability Reform

Privacy Electronic Data Interchange

Security
Administrative Safeguards Physical Safeguards Technical Safeguards

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Case study : HIPAA assessment

The Client: A leading health insurance company in the United States was required to comply with the legislation of HIPAA standards in healthcare Scope : The client had an inorganic growth by acquiring smaller health insurance company resulting in membership and claims process being unique at each site More than 50 databases A number of interfaces and reports Very little process documentation 12 weeks AS- IS process assessment including maps and transaction flow Business Impact and technical document Remediation plan

Timescale Deliverables

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Summary of the findings and lessons learnt

Unavailability of process documentation lead to manually documenting each and every AS IS process resulting in more time and effort Repeatable Process :Encourages cost effectiveness as the process can be used in future compliance related changes It is a business issue not an IT project Successful strategies start with the knowledge of system and impact of each change

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Conclusion: Need for better business process in healthcare

HIPAA became the catalyst for evaluation of antiquated business procedures as well as a catalyst for an integration strategy Process mapping allows us to identify productivity opportunities, best practices ,root causes of problems, create workflow and determine who owns what

Healthcare industry demands reliable and secure transmission of sensitive data Healthcare Industry around the world is under tremendous pressure to reform and to improve the quality of care and service therefore the focus will shift on business process

To conclude, health insurance is a very process intensive business and has to constantly adapt the growing needs of their customer without impacting the quality of care

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Thank you