The perfect medical provider

Emergency
The perfect medical provider

What does a company providing emergency assistance in remote locations look for in a medical provider? Tatum Anderson reports

What does a company providing emergency assistance in remote locations look for in a medical provider? Tatum Anderson reports.

In addition to medical excellence, Julia d'Astorg, Global Head of International Medical Assistance and International Medical Network at AXA Partners, said she requires medical providers to be ready for patients. “We need to select, in advance, the best, most adequate and nearest providers,” she said. “Because it’s not when a person breaks their leg hiking in Thailand that we’re going to start looking at where to put them. And if we sent them to a paediatric hospital, it would immediately be clear that a network doesn’t work.”

For a company like this, the benefit of a provider network is knowing exactly who to contact in a particular location for a particular problem so that time isn’t wasted trying to find someone able to help. “We call our providers when our patients are in need of support and medical care,” d'Astorg said. “Having full clarity on how to get fast access to a bed or an ambulance is key to working hand in hand.” 

AXA has an international medical network department team made up of 40 experts in 26 countries. This team works closely with 80 in-house doctors and nurses to build a network of 40,000 providers worldwide and an additional 890,000 providers in the US. The team of experts is not only passionate about medicine, but able to maintain a good relationship with hospitals, said d’Astorg, and the remit is clear: “Our mission is to assess the best hospitals and experts that are relevant to our customers’ needs. It’s not only about assessing, though, it’s about securing access,” she said.

Best-in-class services 

Unsurprisingly, insurers and assistance companies told the International Hospitals & Healthcare Review that they look for providers able to provide the best-in-class services with reasonable and comparable prices, and those that put the wellbeing of the patient first. 

Companies also said it’s important for medical providers to be open about their limitations. “No provider can provide an end-to-end solution; the best outcome is achieved when we plug in one or more providers. In that sense, trust is very important,” said Elyah Oulad-Mehdi, a colleague of d’Astorg’s and Head of International Medical Network – Europe. “Then we can have an open dialogue.” 

This dialogue involves talking about challenges providers might be facing both internally and externally, as well as their needs. Often, the expert team is working on a regular basis with co-ordinators, nurses and doctors at hospitals with whom they have worked several times in the past. They may even have worked together on cases where they have managed to save lives or, tragically, lost them. “That creates a bond,” Oulad-Mehdi said. 

Trust in partners has other benefits. It enables companies to better anticipate costs, as well as the kinds of services they will receive. “Being able to get an aircraft to take off for a mission that will cost over €100,000 or performing a very urgent and potentially lifesaving surgery just by calling them or sending them an email stating that we will pay is important,” he explained. “This is the trust. Because it is important to know we are working with providers that are not going to take advantage of the situation to make more money than was agreed.”

For Justin Tysdal, CEO of US-based insurer Seven Corners, the benefit of having an established network of quality medical providers is that his members have access to these providers wherever they are located. “We get calls from members who, prior to purchasing insurance, will ask if we work with overseas providers and if we have a website,” he explained. “These two factors are often enough to put them at ease before overseas travel.”

Key attributes

It is important to know we are working with providers that are not going to take advantage of the situation to make more money than was agreed

Tysdal said he looks for certain key attributes in medical provider partners. He wants assurance that providers will accept his insured members whenever they present at a facility for treatment, and also requires ease of access and direct billing facilitates for insured members around the world. Good quality of service and good rates – especially discounts – are also key, as are the location of the facility and reputable reviews. 

Most in the business will be looking for similar attributes, said Tysdal: “I believe the traits looked for by insurers are the same as those looked for by assistance companies. We want to make sure our members are at ease knowing they can get quality medical care without having to worry about the billing portion.” 

Tysdal said that many of the quality medical providers used by Seven Corners are referred by embassies and have positive online reviews. But his company carries out its own due diligence too. “From a claims and anti-fraud perspective, the quality and detail of the medical records as well as invoice consistency and reliability are tell-tale signs we are dealing with a good quality medical provider,” he said. In addition, Seven Corners keeps an eye on reviews via social media sites, and requests and reviews credentials and licences prior to contracting.

A good way for Seven Corners to monitor its providers is to keep track of others in the same area who are not part of the network. “We also look at the locations of other providers and types of services located near the facility,” Tysdal explained.

Different tactics

Insurers and assistance companies tend to have different schemes to assess medical providers. Some perform detailed inspections using their own teams, others use third parties on the ground, some set up rating systems for different hospitals. Assistance company MSO International employs local network managers in strategically important African countries, specifically Kenya, the Democratic Republic of Congo, Nigeria, Tunisia, Senegal, Zimbabwe, Madagascar and South Africa. “This local expertise allows us to quickly shortlist potential partners, who are then vetted against a standardised audit and questionnaire,” said Brenda Durow, General Manager of MSO. Though they are not all clinically trained, these network managers are extremely skilled and use a checklist compiled by the company’s medical team and take photos of the facility and equipment to share with the medical adviser.

Audits also allow companies to differentiate between providers for certain customer groups. High-end members will require a specific kind of provider, for example. “This requires us to limit the network to providers who are able to meet this expectation for a VIP experience, but at a consequently higher cost to the insurer,” said Durow. Expat members, who are more familiar with the area they are in, when compared to a travel policy holder, tend to have different expectations. “Assistance or travel policy members are usually short-term travellers who do not have local knowledge, thus making it a little more challenging to manage their expectations,” Durow said. 

Trust in partners … enables companies to better anticipate costs as well as the kinds of services they will receive

Other companies, such as Seven Corners, for example, have neither formal inspections nor rating systems. Instead, as claims are received they review the invoices and medical documents thoroughly to ensure only medically necessary treatments are performed and prices are comparable to similar providers. “If we receive any negative or questionable feedback from members, we will follow up with the providers and remove our contracts with them as necessary,” said Tysdal. “We do not have any rating schemes; however, based on the type of service, we’d still verify that a cost is justified and not above normal.”

Errant medical providers 

Challenges come when hospitals are not up to scratch. Insurers and assistance companies say they try to steer clear of providers who do not have the wellbeing of the patient as their main focus and clearly try to take advantage of a difficult situation to make money. 

Nola Guirunga, a Network Operations Manager at MSO International, said there are tell-tale signs that a provider is not up to scratch. “A provider who cannot supply the required documentation will raise alarms at contracting stage. However, once contracted, if there are any dubious practices then we would pick it up in their billing or member feedback,” she said. 

When assessing claims, MSO looks specifically for over-servicing, and duplicate or potentially fraudulent claims. “We monitor claims received against usual and customary treatment and tariffs for the area,” she said. “We would also inspect them when we do our regular provider visits.” Here they use the same checklist that was used during the contracting phase and if there are any notable discrepancies from one visit to the next, they would give the facility the opportunity to explain or correct. “If they no longer meet our requirements, we will remove them from our network,” Guirunga explained. 

Quality of service varies across the globe and even within the same country. In the more remote regions of South America, North, West and East Africa, and Nepal, it is often hard to determine the level of medical care that can be provided, said Seven Corners’ Tysdal. In most cases, patients are sent to the only reachable medical provider. The administration of these patients can also be challenging. “Consistency and quality of medical records, as well as invoice formats, vary greatly depending on the culture and location of the medical provider. For similar reasons, not all hospitals have the latest technology, which can result in longer processing,” he explained.

Indeed, political or social unrest makes the Central African Republic a no-go area on a more or less permanent basis, while other parts of the world see periodic incidents of terrorism or unrest. In Chad in Central Africa, temperatures can regularly exceed 45 °C, and storage conditions (especially at customs level) are often poor. MSO said that flexibility is required to deal with these myriad challenges that may not be the fault of the hospital. It has had to temporarily withdraw network managers from Nigeria and Zimbabwe or move patients quickly away from an area where the quality of the medicines cannot be guaranteed due to storage problems.

Having full clarity on how to get fast access to a bed or an ambulance is key to working hand in hand

Flexibility is also key in Angola, where in the capital city there are basic rural clinics as well as sophisticated first-world capabilities. “We have contracted providers who may have the necessary equipment to perform sophisticated diagnostics and treatment and so receive referrals, only to find that the technicians or skills needed to operate the equipment are not available,” said Guirunga. “This could harm the relationship with our client and creates confusion in the minds of members – who know that they should be able to receive treatment, but are then informed it is not available in that facility and alternative arrangements have to be made.”

MSO audits its providers against the benchmark of an average private facility in South Africa, checking everything from piped oxygen or cylinders, to flooring, emergency room staffing and equipment. It assesses the quality of concierge services, radiology, pathology and cold chain storage, among other departments.

There can also be variance in the local legal framework surrounding healthcare and cultural differences in a particular country. Some doctors employed on the continent are embargoed by Zimbabwe, due to their historic association with the previous regime, which makes it impossible for international funders to pay their claims, or even reimburse members. “This requires very diplomatic and transparent negotiations with facilities to ensure that they are able to manage their financial risk, while still providing quality care to our members,” said Guiringa. 

Case-by-case basis 

When members use providers that aren’t within the network, this can cause headaches too, especially when providers do not want to sign contracts said Tysdal. The option then, is to negotiate on a case-by-case basis. “In other situations, facilities do not wish to work with insurance companies based on past experiences and will ask for payment upfront. These are all challenges Seven Corners can navigate on behalf of its members,” he said.

Oulad-Mehdi astutely sums up the need for flexibility and adaptability when dealing with medical providers and ensuring the best for their members:  “Our network is a living and evolving creature, we have to keep our finger on many pulses to understand the impact that social, environmental, geopolitical changes will have on our providers and ultimately on the services provided to our members,” he explained. “We always try to pre-empt them and respond with alternative solutions that take those changes into account. Preparedness is key,” he concluded.