What is your background in the international travel insurance and medical assistance industry, and how has your career progressed to your current role?
I started as a part-time Medical Director for Global Excel in 2006 and literally grew with the company. Most recently I was the Medical Director of an emergency room in Northern Vermont, and through my hospital experience, I knew a lot about the US medical system from the provider side. I was reluctant at first to give up my clinical career, but soon realised that I was learning a whole new language and set of skills. Aerospace medicine, insurance medicine, destination medicine, expat health and, most important, travel medicine. As medical science progresses, it is vital that I keep up with the latest procedures and medications in order to have a meaningful conversation with the treating doctors. I am now Global Medical Director for Global Excel, and as we have offices all over the world, my job includes medical governance, to ensure we are making sound decisions that ensure our ‘patients’ receive the appropriate level of care – and that we are mindful of their policy benefits, thereby taking care of our corporate clients.
As Global Medical Director for Global Excel, there might not be a ‘typical’ day, but what sort of tasks take up most of your time? What do you enjoy and what is most challenging?
A typical day includes a review of the high-risk cases occurring anywhere in the world. These could be patients in facilities that cannot handle their illness or very high or abusive charging facilities. We do interdisciplinary rounds reviewing these cases three times a week, which I head up. This involves the financial, client-facing and coverage teams, alongside medical staff. If necessary, we’ll also bring in our legal expertise. We also do cross-office rounds for destination medicine, sharing ideas and issues. I do a lot of teaching, and this is the part I love the most. The most challenging aspect is ensuring the safety of patients who travel to all regions of the world – not only to common destinations, but also places I have only vaguely heard of.
Do you still get a chance to work in a hospital setting?
I don’t work in a hospital any more, but I did for 35 years. I was a family practitioner in the ‘old days’ when we did everything: ICU, ER, deliveries, paediatrics. It was challenging, but also fulfilling. Now I volunteer at a free clinic once a week because I love the contact with patients, and it forces me to stay current with the newest medical practices. It is vital in my role that I keep my clinical acumen as high as I can because I have to read between the lines of what I hear about a patient’s condition. It is a calculated guess that all the years of practical experience has helped me develop.
I volunteer at a free clinic because I love the contact with patients, and it forces me to stay current with the newest medical practices
Understanding the medical culture of different countries is vital when providing medical assistance and cost-containment services to clients and members. Which are particularly unique/challenging from a medical case management point of view?
There are many aspects of care that bring to light cultural challenges. Every country is different
and there is wide variation in how medicine is practiced around the world. Understanding this is a key component to my job. For example, it’s not possible to take a patient off a ventilator and let them pass away in Thailand. In that country, it is against the law to terminate care and, at one point, we had to air ambulance a person home to Toronto to then take him off the ventilator.
Japan is a challenge because they will not release any medical information until the person is discharged. The standard of care is acceptable, but case management is very difficult.
Canada is not dissimilar; I think the countries that have universal healthcare, and are not used to private insurance, don’t understand the concept of case management as it pertains to cost containment.
The countries of the Caribbean have very different abilities to handle critically ill patients, and although some will be up front and ask to evacuate the patient, others hold them longer than they should.
Cuba continues to be a unique country in that Assistor is the only TPA (third party administrator) there. We have an excellent relationship with Assistor, but having them function as the sole TPA for an entire country isn’t easy.
Mexico continues to be challenging, from withholding care if no guarantee of payment is made immediately, to using unscrupulous third-party companies who often multiply the actual billed amounts by significant factors when creating international invoices. The quality of care varies widely and is not really related to the cost. This makes ensuring the proper level of patient care a problem. We do have an office in Mexico and so have the advantage of ‘boots on the ground’ to help.
How is Global Excel using technology more effectively to enhance analysis of medical billing protocols and identify potentially fraudulent claims from providers?
Healthcare billing and pricing is extremely complex, which is why cost containment, bill review and fraud detection have become standard, but vital specialisations at Global Excel. Several years ago, our teams decided to leverage AI technology to give us the ability to focus on the abusiveness of a bill from $1, rather than having to base our actions on a threshold – we called this solution X-Routing. We increased our ability to review a larger volume of bills, catching potential fraud and quickly sending it for review, investigation and negotiations. Our medical staff across many regions, including myself, are often involved in reviews.
This complexity plays out internationally, where you see massive variations in healthcare pricing (together with availability and quality). In the US, a provider can charge whatever they want for services, while the payer is left just trying to pay a reasonable price at the end of the day. Globally, healthcare cost inflation rates continue to rise much higher than general consumer inflation.
Overall, we combine traditional billing processes and protocols with cutting-edge digital solutions to increase efficiency, as well as involving our highly experienced staff, resulting in consistently identifying and preventing fraud.
Cost containment is a much more complex process than it used to be – it’s not as simple as negotiating discounts on hospital bills. What are the significant changes you have witnessed?
Being able to offer a familiar experience, with accessibility to quality care anywhere in the world, is the new gold standard
Absolutely. Real-time healthcare risk management means proactively preventing or mitigating unnecessary costs throughout a patient’s entire medical journey, instead of waiting until it’s over and then trying to ‘contain’ costs after the fact. Traditional ‘cost containment’ is retroactive, and although necessary, it’s more a method of trying to clean things up after the damage has been done.
Digital-first services and solutions used to be nice to have, but are now a standard offering expected by members. Being able to offer a familiar experience, with accessibility to quality care anywhere in the world, is the new gold standard. While members want an unprecedented level of self-service and access, many still prefer speaking with a human being in their own language. At Global Excel, we refer to this as providing the right care, at the right time, in the right location and for the right cost. This is how medical case management becomes so valuable: our involvement in the decision-making process through each step of a member’s experience provides both better care and control over the costs involved, primarily by avoiding unnecessary expense from the beginning.
How have US hospitals adapted to recent legislative changes in billing practices, and how has this affected your ability to work with them?
In the US, healthcare pricing remains completely unregulated, with significant variations from state to state, city to city, provider to provider. The recent Hospital Pricing Transparency Act and No Surprise Act are steps in the right direction, but the effects are on domestic cases and our travel business has not been impacted.
We continue to manage cases with very little change; however, we remain proactive in our approach to simplifying cost management while netting far better returns. Getting involved early in the process of determining a patient’s healthcare needs is essential to steering them to the right type of care, which can drastically reduce costs. As much as possible, operating within a trusted network with pre-negotiated rates is another excellent way of avoiding unpleasant billing surprises. These two major elements combine with expert bill revision to provide payers with a highly competitive solution.
With the help of our TPAs, we can make the patient and family feel like someone is helping orchestrate their care and safe return home
Training up and retaining a new generation of travel insurance/international healthcare professionals is increasingly challenging. How is Global Excel addressing this issue?
Global Excel has an excellent reputation in the market – and there are a lot of very good candidates out there looking for alternate health careers. I think emphasising that we are not a hands-off, cold authorising board, but a company that cares about the patient and is trying to do the best for them within policy limits and the country they are in, has made it easier for us to recruit and retain quality personnel. Imagine having to negotiate your own emergency in an unfamiliar country, without our assistance. With the help of our TPAs, we can make the patient and family feel like someone is helping orchestrate their care and safe return home. But I’m also learning something new every day with the challenges of new treatments, medications and the presentation of rare diseases.
If you could give one piece of advice to someone starting their career in this industry, what would it be?
Never become complacent. Remember that there is a person on the other side of the policy, and if you can really help even just one individual, you will carry that feeling of success with you.