Smooth operations

Smooth operations

When an insured falls ill or is injured abroad, this triggers the exchange of huge amounts of information between assistance and insurance companies, hospitals, and doctors at home and abroad. Tatum Anderson and Mandy Aitchison talk to those involved to gain an insight into the issues they have when it comes to working together, and ask how these issues might be resolved

When an insured falls ill or is injured abroad, this triggers the exchange of huge amounts of information between assistance and insurance companies, hospitals, and doctors at home and abroad. Tatum Anderson and Mandy Aitchison talk to those involved to gain an insight into the issues they have when it comes to working together, and ask how these issues might be resolved

The flow of information regarding an insured patient needs to be as streamlined as possible to allow for timely treatment and to provide peace of mind that a patient will be covered by their insurance. But the sheer volume of paperwork this involves, and the number of channels this information needs to pass through, often make this an arduous task.

Such paperwork could include the patient’s diagnosis, whether further tests or surgery might be required, when a patient might be fit to fly, their visa information, police reports, identification (such as a passport), signed consent for the acquisition of medical records, and direct billing terms. Only when such information has been collated can the assistance company issue a final Guarantee of Payment (GOP) – the green light that a medical procedure and hospital stay is covered.

Hospitals, too, often need to dedicate a great deal of time and staff to managing information related to their foreign patients. As such, many hospitals that treat a significant proportion of such patients now have international departments or international patient coordinators dedicated to liaising with these patients, the treating doctor, and the assistance provider.

many hospitals that treat a significant proportion of such patients now have international departments or international patient coordinators dedicated to liaising with these patients

So, it is not surprising that the exchange of information between all the parties that have a part to play in the processing of an insured patient who finds themselves in need of care in a hospital outside of their home country can be fraught with difficulty. Indeed, there is more than a little friction between hospitals and assistance companies, with both complaining that the process of working together can be very slow – and both agreeing there is considerable room for improvement.

The problem with hospitals

One of the main issues that assistance companies cite when talking about the issues they have when it comes to working with foreign hospitals is of delays in receiving patient information. Some delays cannot be helped: patients may leave their insurance information or ID card in a hotel safe instead of bringing it into the hospital with them; but other delays come down to cultural differences, inefficient internal processes, and a lack of trust in payers.

Meredith Staib, general manager of assistance operations at CustomerCare, an Australian emergency medical evacuation services company, says some hospitals in some countries just don’t understand the insurance process. “Hospitals in Bali and Thailand know our processes and send us all the required information on admission,” she says, “whereas in Japan and China it can be very difficult to get the same level of customer information.” But problems with delays aren’t just associated with public sector hospitals. Allianz Global Assistance, for instance, suggests that some private hospital networks in Turkey, Greece, the Dominican Republic and Iberia are particularly difficult to work with, and delays are a real issue.

Hospitals concede that some problems are of their own making, and they agree that they are often unable to keep up with complex insurance documentation. Danny Quaeyhaegens, head of the international insurance department at Bangkok Hospital Pattaya, jokes that his establishment employs neither lawyers nor insurance underwriters who specialise in small print and implicit exclusions, yet it must treat 10,000 foreign patients each year and understand hundreds of different insurance policies. He also agrees that hospitals and doctors can be slow in delivering medical reports or hospital administration teams slow when issuing price quotes. 

Assistance companies explain, however, that the information they request from hospitals is needed in order to issue a GOP. The issue here is that hospitals, generally, wait to receive a GOP before commencing treatment; but in urgent or emergency cases, treatment may have to commence before a GOP arrives. Unfortunately, some hospitals have been accused of delaying treatment even for emergency patients, as they insist on waiting for the arrival of a GOP. As Laurent Verner, medical director of Allianz Global Assistance, says: “The emergency is always a guarantee. [Hospitals] don’t understand we can’t take [into account] all the medical procedures, but we have to decide step by step according to the medical status of the patient.” For example, if a patient presents with chest pain, Allianz says it can oversee the stabilisation of the patient in situ. But once the patient is stable and if they need a by-pass, the next step would likely be to organise medical repatriation for that particular procedure rather than issue a GOP for the procedure to take place in the hospital outside of the patient’s home country.

Hospitals concede that some problems are of their own making, and they agree that they are often unable to keep up with complex insurance documentation

Assistance companies also say hospitals sometimes keep patients in for too long and perform too many procedures and investigations.

Assistance companies also complain that some hospitals, particularly in Asia, demand security deposits or cash bonds to act as a line of credit when discussing partnership establishments with companies. Kellee Hinshaw, an assistant manager dealing in international provider relations at US-based Seven Corners, says her company’s accounting policies mean that advancing credit to hospitals is not allowed, especially if might sit in a bank for an indefinite period; so remedies must be sought.

It’s not surprising, then, that billing can be a real headache. According to Seven Corners, despite including references with every invoice when wiring transfer payments, it has to deal with constant enquiries from hospital providers asking where the money is and dealing with their confusions over accounts. This is a major issue in some Asian countries it says, as well as the United Arab Emirates. “We spend a great deal of our time essentially balancing the books of several hospitals, because they can’t seem to do it themselves, even though we are providing them with the necessary details to do so,” says Hinshaw.

That's not the only problem. Seven Corners says it negotiates good, workable direct-billing agreements with high-level hospital managers who are often in charge of several hospitals in a group. Despite that, it comes across members of staff that deal directly with patients who are woefully uninformed of these agreements.  “I cannot tell you how many times someone from patient services or credit control at one of our contracted hospitals has refused to direct bill initially, stating they do not have an agreement with us,” says Hinshaw. Sorting out these bureaucratic blips wastes time, she says. “We’ve lost hours, if not days, where the patient either isn’t treated; or has to pay upfront because hospital management did not inform relevant staff that an agreement has been established.”

Insurance and assistance issues

Delays in the communication of information between assistance companies and hospitals come down to a variety of issues, none of which is helped by distance, language and cultural differences. Time differences can also be a hindrance, as can bad Internet connections and phone lines. And although the widespread use of English eases many communications, some report language problems in Eastern Europe and amongst Russian-based assistance companies. Peak periods in June, July and August exacerbate these matters, making it difficult for hospitals to get the go-ahead they need to treat patients in a timely manner. “We do not get the information needed from the assistance company quick enough in order to put the patient’s mind at rest,” says Francisco Jose Rico Ortega, international relations manager from USP Hospitals in Spain.

Furthermore, red tape can cause delays because different countries have individual policies and procedures that must be adhered to when sharing patient information. For instance, many companies dealing with British, Australian and, to a certain extent, Russian patients must undertake a lengthy process to check pre-existing conditions by contacting the patient’s GP directly.

Dr Juan Bosco Rodriguez Hurtado, clients and business development manager at Xanit Hospital Internacional in Spain, says: “Unfortunately, as regards assistance company feedback, time is scarce, most especially when they need to request inpatient medical reports from the corresponding GPs that will clear up any doubt regarding previous medical history. The whole process is, most of the time, delayed, and so is the issue of a final guarantee of payment too.” In cases where pre-existing conditions need to be investigated, the response time from insurers can be even more substantial, as Judy Mitchell, marketing manager for international insurance and western markets at Bangkok Hospital, explained to ITIJ: “If pre-existing conditions are excluded and a patient presents with a symptom  (chest or back pain, as common examples) that may be indicative of one, coverage approvals or denials will in some countries take a week or longer to receive, while everyone waits for the insurance company to verify this condition with the patient’s GP. In such cases, Bangkok Hospital will invite the patient to pay and claim.”

But, occasionally, some hospitals accuse insurers or assistance companies of deliberately delaying GOPs. One hospital told F that with some conditions that are not life-threatening or dangerous (but that can seriously curtail the enjoyment of the patient's holiday – an abdominal hernia, for example), authorisation is delayed in the hope that the patient might wait until they get home to seek medical attention in order to avoid administrative hassle.

Insurers tread a fine line, though, between issuing a GOP as quickly as possible in order to provide peace of mind for the patient and approval to treat for the hospital, and taking the time to make sure they are providing approval in line with the strict terms of their cover. All the while, insurance ombudsmen are keeping a close eye to make sure this timing is not stretched to unreasonable lengths. The UK’s Financial Ombudsman Service, for example, told ITIJ of cases it has looked into regarding complaints of circumstances where a claim has been delayed because extra information had been requested unnecessarily. This seems to be a particular bugbear with consumers – if the client simply fell and broke their leg, they see it as unreasonable for the insurer o spend two days looking at their medical records to decide if the claim is valid.

The frustration doesn’t end with customers, as we have already seen. “From our point of view, assistance companies are becoming more and more difficult to work with,” says USP’s Ortega. “In general, they do not provide enough information and [they don’t provide] timely information. This could be improved by both parties – assistance companies and hospitals.” While hospitals are accused of being slow at gathering the information required by assistance companies, some that ITIJ spoke to did admit that they understood that if they could gather the information more quickly, assistance companies could resultantly issue GOPs in a more timely manner. As Mitchell says: “Hospitals need to work hard to quickly update the companies via prompt, accurate and insightful medical reports to help the clinical team of the company understand the case and the proposed course of actions, as well as cost estimates.” Carla Frankart, director of the American Rehab and Urgent Care Centre in Landstuhl, Germany, agrees: “Having the claim presented in a legible manner with the medically necessary documentation for reimbursement is a must for the insurer.”

However, Ortega explains that often even when payment authorisations are issued, they are not as simple as hospitals would like. Instead of a simple GOP, many are issued with a plethora of caveats or conditions. “They include some small print in their GOP that would give them the right to withdraw the guarantee under certain circumstances,” he says. “Of course, a hospital in a foreign country cannot work like that. If an assistance company says it will pay, they will need to pay, and if they think that they sent a guarantee of payment unnecessarily, then they should still keep their commitment to the provider and then, later, clear this up with their customer.”

While hospitals are accused of being slow at gathering the information required by assistance companies, some that ITIJ spoke to did admit that they understood that if they could gather the information more quickly, assistance companies could resultantly issue GOPs in a more timely manner

It’s not entirely impossible to understand why some hospitals form the opinion that insurers do everything they can to ensure they make the smallest pay-out for patient care. As Karen Parnell, a senior administrator at the International Medical Center in Lavigno, Italy, previously told ITIJ: “We are really seeing some unacceptable situations occurring when the patient really needs them to respond, and often quickly, and they are more interested in the invoice than the patient’s wellbeing!”.

Needless to say, some assistance companies feel their role is too often misunderstood. Verner explains that the issuing of guarantees is complex and can take time because each medical assistance contract includes its own warranties and conditions. “It’s the reason why it’s not possible to guarantee all payment immediately,” he says. “Before taking the payment, we have to check medical information and warranties. We understand the payment issue of hospitals, but our priority remains to take care of the patient in the best conditions.”

CustomerCare’s Staib says misunderstandings are unfortunate. Her company requires extremely detailed patient medical details to satisfy the insurance or assistance company they work for. “Sometimes, treating doctors or medical staff may feel that we are questioning their care,” she says. “We aren’t, but we require essential information as per our customer’s policy, as well as to determine the appropriate plan for their discharge or repatriation home.”

In many cases, issues between providers and payers come down to trust. Seven Corners says, however, that there is so little trust in the industry that some hospital providers refuse to work with them if they have had bad experiences with other international insurance companies. Much of the mistrust has come about because providers have not been paid in the past; which is why in so many countries of the Middle East and Southeast Asia, hospitals insist that international assistance companies use local agents with offices in the country.


Where does the buck stop? Who is ultimately responsible for the delay in communicating information, and what can be done to make relationships between assistance companies and hospitals run more smoothly?

As Quaeyhaegens of Bangkok Hospital Pattaya diplomatically puts it: “All parties involved (patient – provider – assistance company – Insurance company) have their responsibility in making the process smooth.” Certainly, it would seem that there are obvious areas where communications can be made more efficient, and these areas lie both in the assistance and insurance industry camp, and that of international hospitals; and there is a need to tackle issues regarding delays that lie outside of these parties’ control, as well as inside.

It has been suggested by assistance industry personnel that a key way to improve these issues is to build a better rapport with staff at the treating hospital, and to get them up to speed with insurances process for future cases. Frankart explains: “As the [medical] provider, having a contract with the insurer [that includes] clear direction on how to proceed with the claims process and verification of benefits status [is very helpful].”

Such contracts and effective communication strategies would stop hospitals from treating patients without first finding out whether the patient is covered by their insurance, and would smooth the way for more efficient processing of insured patients. In situations where hospitals and assistance providers or insurers have established good working relationships, processes are automatically put in place to make communications more efficient. As Jithu Jose, general manager of the international patients division at Apollo Hospitals in Chennai, India, told ITIJ: “Most of the companies we deal with have a 24/7 call centre number. In addition, they provide us [with] member verification details by which we can attend to their clients without any pre-authorisation in case of any medical emergencies.” He added that most insurers or assistance companies also provide dedicated provider relations managers, online verification of cards, and online tracking of payments, stating: “And we would like such facilities with all of them.”

Training is essential to achieving better relations, believes Staib, as well as remaining in constant communication with hospitals over patient cases, and building trust – and one way to do this is for both hospitals and assistance providers to be up front about what exactly can be delivered and when. “Trust and respect between CustomerCare and our customers leads to better outcomes,” says Staib, “and we do this by communicating clearly with both our customer and their treating hospital, being transparent, managing expectations from the outset and striving to deliver what we say we will.”

effective communication strategies would stop hospitals from treating patients without first finding out whether the patient is covered by their insurance

Trust is also important when trying to establish billing agreements with hospitals overseas. Seven Corners proposes some practical solutions to common problems in this regard: if a provider refuses to sign an agreement, it suggests working together on a trial basis. If a security deposit is requested, Seven Corners presents audited financial statements and references from other hospital partners around the world. If the hospital refuses to bill it directly, it offers its corporate credit card and, finally, if there are payment reconciliation problems, it issues a raft of detailed information – including spreadsheets – so that everybody knows exactly who has been paid and when.

Indeed, everyone contacted by ITIJ agrees that many of these issues would be ironed out quickly with far more communication between assistance companies and hospitals. International departments within hospitals certainly help in this regard, with some hospitals, such as Bangkok Hospital, further aiding communication by supplying dedicated medical staff to the job of liaising with assistance clients, which can be especially useful in cases where the treating doctor and the assistance company medical director may have differing views on a patient’s care pathway. As Judy Mitchell explains: “If there are questions, we always have a dedicated primary care physician for each insured patient, whose job is to proactively work with the medical directors of the assistance or insurance companies to improve communication and understanding on the clinic side of things. This has proved very useful to improving communication and understanding in this area.”

Not all hospitals can justify setting up an international department, but where they do exist there have been concerns that many only have administrative staff working five days per week. As with the problem of GPs generally not working on weekends, this situation of not having the right people available 24/7 will inevitably lead to delays in communicating patient information.

In line with making sure the right people are available at the right time, it has been suggested that claims handler staff are better equipped to deal with coverage enquiries, and that such staff could be on hand 24/7. As Frankart points out: “Most [insurance] carriers have a 24-hour call centre, but sometimes the representative answering the line does not have enough information and you receive more feedback when you call during working hours.”

Furthermore, assistance companies should always be given the authority or mandate to independently issue approvals: as Judy Mitchell explains, “[When an assistance company cannot issue an approval] the problem is worse because the hospital has one additional company between itself and the decision-maker for coverage approvals.”

As we have seen, in some cases, better use of technology can enable smoother communications. For instance, today some hospitals have developed their own electronic case systems to manage patients' information, and assistance companies also have portals where information can be posted instead of relying on emails or faxes. Staff at Bangkok Hospital Pattaya routinely upload information and gather information posted by assistance companies about patient cases on websites run by companies including VanBreda and SOS International Denmark, and Jose also commended these systems, saying: “It is all about accessability and response factor. Vanbreda has a simple and easy to monitor online model to access. We do have other companies with such online systems, but our insurance team has rated these two as the best ones.” Similarly, Xanit’s Hurtado thinks the exchange of information would be improved immensely if more communication took place using the kind of real-time chat facilities available on many websites.

Local agents have also proved to be useful for avoiding some of the stumbling blocks that arise due to cultural and time differences, and for enhancing medical providers’ feelings of trust in international payers. The things to check about such agents, aside from their experience and reputation, is how many employees they have, their positions of authority, and their language capabilities. Simply accepting the promise from an assistance company of ‘an office in every major country’ is simply not enough.

Allianz proposes that the hospital and assistance industry should gather round a table, such as at international events, and discuss their objectives and practices to ensure the patient gets the best results. “Communication is key,” says Verner. “If all health parties communicate together, the vicious circle between insurers, patients and hospitals will be broken. Communication is in the interest of all."