Building relationships - healthcare and insurance providers

Clear information and communication

Clear information

Firstly, we have to identify the pain points in the relationship if we are to address them and find solutions. Let’s start with transparency between provider and payer.For Lara Helmi, Managing Director of CONNEX Assistance, “understanding the real capabilities of a facility” is a great place to start. She said: “Our medical network is audited at regular intervals depending on our volume and location of the facility. Above all else, we need to understand the real capabilities of a facility so we can assess which types of medical cases they are able to treat, and which they may not. We need to understand their medical staff capabilities, their equipment, and particular centres of excellence they focus on.”   

Part of this information process is ensuring that facilities have the appropriate licences in place to treat patients. Guskova said that while it can be a time-consuming and lengthy process, having detailed audits of providers and their capabilities is “of paramount importance”.

Communication

“Clear and highly responsive communications are key,” Helmi told ITIJ. And it doesn’t matter how good your medical equipment is and what the surgical outcome rates are if the staff aren’t able to find out how the patient is doing. “Any alarm centre coordinator will tell you they are relieved when we are handling complex cases at a facility which has a highly responsive team assisting us with our case management requirements,” Helmi added. “We can actually avoid a state-of-the-art facility simply because their patient services team do not respond quickly enough to requests for estimates, updates on the medical condition of the patient or requests of our in-house doctors for information, or our invoicing requirements.”AP Companies has a global network of medical providers, and having extensive language capabilities in-house is key: “Our network, operational, and payment teams are proficient in communicating in over 30 languages, ensuring that we can always establish effective communication with healthcare providers, even in the most remote locations.”

AMREF Flying Doctors, based in Nairobi, Kenya, provides assistance services in Africa, and according to Jane Munyua, Medical Assistance Manager, the key problems they encounter also centre on inconsistencies in communication with private hospitals: “An email or telephone number may go unanswered. Language barrier is not uncommon sometimes. On follow-up of patient progress reports as an example, you may find that some of the consultants are too busy to write a report or are not easily available for a one-on-one conversation with the AMREF Flying Doctors team.”

Keeping costs down

‘Cost containment’ aren’t dirty words in the industry any more. Maybe they were 20 years ago, when it was more about brutal negotiating tactics and refusing to pay medical bills in a weird game of chicken that often left the patient stranded without any help, and eventually being balance billed. Nowadays, cost containment means something different. It means the hospital can provide cost-effective care, and the assistance company knows it is getting value for money. Another potential way of keeping costs slight lower is for providers to be paid in local currency: “We maintain local representations in various countries, facilitating payments in local currencies whenever necessary,” explained Guskova. “Furthermore, we recognise that conducting transactions in local currencies can ultimately serve as an effective cost containment strategy, leveraging our local offices to curtail our clients’ medical expenses.”

The right care in the right place

Unfortunately, travellers can’t be relied upon to stay on the beaten track on their adventures, and although assistance companies can have a network of hospitals and clinics, inevitably, there will be times when the client is in a location where there isn’t one. Guskova explained to ITIJ how it can be possible to keep clients as safe as possible: “The final significant challenge we address is the scarcity of medical facilities in specific locations. As we serve a diverse clientele, some of whom may be situated in remote areas where hospitals are scarce or the available facilities may not be suitable for their needs, AP Companies is committed to transparency. In such instances, we provide our clients with comprehensive information about local options and the best available healthcare alternatives nearby.”

Taking a hard line against facilities that are trying to extort additional fees from assistance companies is important, but it is a fine balancing act to ensure that the relationship isn’t ruined forever, and that the client/patient isn’t caught in the middle

When it all goes wrong…

Unfortunately, there are always going to be a few black sheep in the family. You aren’t going to run a medical network of hundreds of facilities all over the world without encountering one or two that may not be playing by the rules. While sometimes this might mean overcharging for a few litres of saline, it could also escalate to insurers being billed for procedures that never happened, care that was never provided, or a patient that never existed. Directing clients away from facilities that we know engage in fraudulent actions has limited efficacy, because nine times out of 10, the patient is going to head to the hospital recommended by the travel agent or hotel. They aren’t going to ring their medical assistance company first, no matter how many times the policy urges them to do so.

So, when the bill comes in from a non-networked hospital that may or may not be somewhat inflated, what are the most effective ways for a medical assistance provider to ascertain whether or not the bill is fair? Research, and local knowledge, said Helmi of CONNEX Assistance. She told ITIJ: “Whilst we do our best to steer patients away from these facilities, unfortunately many patients tend to visit facilities recommended by travel agencies or hotels, who have commercial interests in place, and the insured only contacts their insurer or assistance provider when it is too late. Many facilities will offer misleadingly high discounts, which seem like a good deal but are in actual fact still extremely high in cost when compared to similar treatment in the patient’s home country in much better-equipped facilities. To avoid these false discounts, we operate on a basis of the average case cost in tourist areas, where we pay the fair and customary amount for a specific treatment, saving insurers and international assistance companies from paying exorbitant prices.”

Taking a hard line against facilities that are trying to extort additional fees from assistance companies is important, but it is a fine balancing act to ensure that the relationship isn’t ruined forever, and that the client/patient isn’t caught in the middle. AP Companies takes a multifaceted approach to the problem, which can result in a hospital being blacklisted, but only as a last resort: “Our strategies at AP Companies encompass various layers of vigilance, from general practices, such as monitoring reasonable and customary (R&C) rates in all regions where we operate, to specific measures that encompass controlling provider price lists, challenging price hikes, negotiating discounts across multiple tiers, conducting rigorous cost controls on each case, and, when necessary, delisting providers that fail to respond to fair and reasonable measures.”

The team also seeks to secure various types of discounts, including volume-based discounts, prompt payment incentives, and long-term partnership agreements. Technology also comes into play when audits occur, as artificial intelligence (AI) can spot patterns of abusive billing where the human eye may not. AP Companies leverages data sharing and harnesses analytics through the implementation of cutting-edge technology solutions. By facilitating data exchange, payers can collaborate with providers in identifying opportunities for improvement by analysing utilisation patterns and outcomes. And it works both ways, as Guskova pointed out: “Conversely, providers can share insights on cost-efficiency and patient outcomes to demonstrate their value.”Munyua told ITIJ that in some cases, the hospital can see that a patient has insurance and use this as an excuse to start abusive billing practices: “There have been cases, especially in small private facilities, where the staff and patient may collude to defraud the insurer and send exaggerated and inflated bills. Where we suspect that a hospital has overcharged, we will most times go a step further to discuss the charges and request a discount, which in most cases is accepted. Overcharging is mainly noted in small hospitals that will mushroom up in areas where there is usually an influx of foreigners (tourists).” AMREF Flying Doctors has set up service level agreements with most local hospitals and this is the guiding document as to how much a hospital can charge. Kenya’s Medical Practitioners and Dentists Council also provides a guide as to how much should be charged by hospitals.

Getting the relationship right – be fair and be honest

Whether it is a relationship with a loved one or a business colleague, being fair is essential to a smooth-running operation. If the relationship is weighted more to one side than the other, then it will breed resentment and, inevitably, suffering will follow – and we don’t want the patient to be the one that suffers. Work together, be honest about expectations and abilities, and there’s a much higher chance that happiness (i.e. a good medical outcome, a medical provider that has been paid, and an insurer that is confident it got value for money) will be achieved. As Helmi said: “We maintain strong relationships with all our providers, and the nature of our business means we have to be able to work with everyone. To be able to effectively do this, we always operate on the basis of fairness for the patient, the facility, and the insurer … and our medical teams work closely together to optimise treatment plans for patients.”

We prioritise the development of standardised contracts and agreements

Transparency is perhaps the word of the day in this situation. For AP Companies, certainly, they are keen to highlight the importance of a transparency payment process, which eliminates misunderstandings and delays. “Fundamentally,” said Guskova, “we hold the belief that open and transparent communication is paramount. Both parties involved should engage in regular, clear, and candid dialogues. This entails sharing critical information concerning reimbursement rates, billing practices, and any alterations in policies or procedures.”

Standardisation of contracts is perhaps not something that would work for everyone in the industry, but it is something that ITIJ has written about in the past that could help to minimise the risk of misunderstandings between payers and providers, whether healthcare institutions, assistance companies or air ambulance operators. Guskova expanded: “We prioritise the development of standardised contracts and agreements. These documents articulate payment terms, service expectations, and dispute resolution mechanisms in a lucid manner. Standardisation simplifies the comprehension of obligations and rights for both payers and providers.”

Munyua agreed that the relationship between payers and providers could be improved with clear contracts and information: “Documentation and policies are usually the guiding principle. A credit policy that is well defined and understood by both the payer and provider smooths the working relationship. Expectations are then clear for both parties.” The keys to any relationship being successful over a long period of time are clarity of information and good communication. Where money is involved, these become ever more important. The payers we spoke to are keen to ensure an open and honest dialogue with their medical providers, and, in doing so, hope to ensure value-based pricing and quality care for the clients.