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medvisa 2

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Prezibase Designs

on 28 November 2016

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Transcript of medvisa 2

KSA Presentation
MediVisa
Riyadh, KSA 2016
MediVisa Group is a Third Party Administrator offering comprehensive health insurance management solutions to Medgulf and large self-funded schemes.
Relies on a robust IT system and invests continuously to enable online and EDI capabilities. Today the system current database size, in KSA only for example, has reached 60GB with over 25m claims and still works smoothly.
Operates a large network of over 1,200 healthcare service providers and applies highly effective and efficient control protocols to claims management procedures.
Operated by a team of over 500 highly skilled professionals having extensive field experience in the Kingdom of Saudi Arabia.
For more than 22 years, managed a large portfolio of beneficiaries, which has today reached over 1,500,000
Corporate Services
Policy Briefings
Pre-authorizations
Concurrent Review
Claims Adjudication
Case Management
Claims Processing
Customers and Providers Support
Healthcare Providers Relations
Statistical and Technical Support
2016 and beyond
Need to enhance client outreach through capturing insured members mobile numbers.
Will continue exploring and implementing decentralization of functions on basis of best quality and lower cost.
Will continue investing in training our staff and nourishing the operations with additional resources.
Need a complete marketing plan that highlights to clients all our joint services which are a match to competitors.
Need to continue investing in IT development and expand electronic claims capabilities.
Need to offer additional services that attracts new clients.
Need to nourish Fraud detection to achieve extra savings.
Need to enhance network relation to achieve more volume and PP discounts.
Our Vision
To Be The Absolute Best TPA, Measured By The Value We Deliver To Our participants/insured members
Service :
Briefing Process
Policy issued & sent by Medgulf
Medgulf
MediVisa
MediVisa
MediVisa
MediVisa
Medgulf
employees
6
Electronic copy + hard copies sent to MediVisa
Electronic copy verification
Briefing sent to providers
Confirmation received from HCPs
Copy of confirmation sent to Medgulf/ Client
What we need to know
Review the Policy & its application on the system & report any flaws.
Create an E-summary for internal use (Approvals, Audit, & Customer Service Center).
Add any special provisions or notifications to MediVisa’s system where necessary.
Policy Briefing
1
What they need to know
Policy Classes (VIP, A, B, C)
Benefits & Limits
Exclusions
endorsements and updates from Medgulf

Special Provisions
Pre-approval Requirements
Service 2: Pre-authorization
Approval Process
7,000/day
Approval received from HCP when service/ illness requires an approval
Request reviewed by MV doctors; approve/reject/ second opinion/ more data
Approvals are sent electronically or by fax.
UCAF, DCAF, or OCAF format used.
An approval takes on average 13 minutes. (CCHI – 1 hour)
Doctors will notify CSC in respect of flagged insured members, VIPs, etc.
55 employees
Service
3
Concurrent Review
Concurrent Review Process
During the patient’s stay at the hospital, MediVisa’s medical team will visit to monitor his/ her course of treatment & medical Status. In case the patient suffers any complications, information will be obtained to certify additional days.
18 employees
Case Management
Service
4
Case Management Process
This service helps in facilitating the appropriate health care services for patients by our team of medical consultants.
The aim is to promote the best outcome for the patient & to control the cost of treatment.
Claims Adjudication
5
Service
Direct Billing & Reimbursement Process
Invoices received from HCP & Clients
Our doctors review if medical and technical charges are in order
Rejections reasons are stated on the claims
Audited Claims are sent to Claims Department to be processed accordingly
Processing
System
Batches
Letters
82 employees
Service
7
Customer Services
Claims Support Center works as a buffer zone between the client & the approvals department.
They maintain a neutral position in order to get to the best decision possible.
Call Center
36
employees
Support
26
employees
Customer Services
7
Service
CSC Officers’ Duty
To promptly handle Clients’ different queries regarding their policies’ coverage & exclusions.
Pre-Authorization is obtained & attached when applicable
To promptly handle all complaints & give a proper & satisfactory reply.
To offer additional services for insured members relying on MediVisa’s strong connections in the healthcare industry (e.g. granting MV’s contractual discount for uncovered cases).
To record all queries for later assessment on how to improve the quality of service.
Services provided are relevant to the medical case.
Providers Relations
Service
8
How it
Providers Relations is done in coordination with Medgulf’s Network Department.
It operates based on periodical review of each HCP’s performance in terms of cost efficiency & quality of service.
Works
Providers Relations
Service
8
MediVisa aim is to
Control the cost of claims.
Determine the HCP’s level (Class VIP, A……etc.).
Detect any fraud attempt or abuse.
Negotiate new discount & package deal agreements.
Take appropriate action to any deterioration in the quality of service
Statistics
9
Service
Statistical Reports from MediVisa
3 employees
Examples:
- Frequent Illness.
- Cost by Age/ Relation.
- Deductible recollection.
- Abusers Report.
- Policy Cost per HCP.
- Report by Benefit.
Examples:
- Policy Portfolio.
- In-House Clinics.
- Burning Cost.
- No. of Insured.
Custom made reports
Standard Reports
Reports jointly
analyzed by
Medgulf & Medivisa
Managements
MediVisa System and TriCast generates
Daily
Weekly
Monthly
Annually
Processing Performance
Call Center Performance
Pre-Authorization Performance
Fraud Detection Visits
Claims Paid, Outstanding & IBNR
Preauthorization Ratios
Processors Averages
MediVisa in Numbers
Outstanding
Doctors Performance
Delegates Performance
Rejection Ratios
Full KPIs
Claims Paid, Outstanding and IBNR
Full Analysis of all departments Performance
Our mission within an integrated business cycle (COP)
MediVisa
Sales
UWD
Competition
Abuse
Fraud
Control

medical costs & keep them within reasonable bounds.
Organize
& maintain the provision of benefits.
Protect
the health of beneficiaries by ensuring easy access to quality healthcare facilities
Contents
The road ahead
MediVisa in Numbers
Services
Overview
MediVisa
Insured Members
Full transcript