ITIC MENA: Managing medical assistance cases and claims costs

John Spears, VP Marketing and Business Development, Global Excel

John’s presentation began by showing the flaws in the historic approach to cost containment, identifying the primary problems: ‘cost containment used to be retroactive, not focusing on the member or even the whole claim, and the fact that success was evaluated based on a percentage of savings’. “Change is needed,” he continued, “because healthcare inflation continues to outpace consumer inflation, overtreatment has become more prevalent, and cost/quality ratios differ significantly between providers. There is no statistical link between prices and quality of care,” he warned attendees. Of concern, he continued, is that international providers are now looking to the US for pricing ‘inspiration’. Increases in healthcare spending is the biggest challenge for travel insures, who are going to be seeing increases in their spending on US healthcare costs, and are going to find it difficult to increase customer premiums accordingly, said John.

The need for proactive risk management that prevents, mitigates and contains costs, is, therefore, more essential than ever, said John. “Risk management needs to be done at all stages in the claims process, should coordinate with assistance and case management professionals from beginning to end, and needs to enhance the member journey.”

John identified several ways that cost escalation can be mitigated and the risk of high claims costs prevented and mitigated:

• Policy wording: ‘a policy will cover reasonable and necessary costs’
• Exclusions: for instance, if a hospital makes an error in patient care
• Preauthorisation: enables process evaluation
• Assistance and patient direction: providing the right level of care in the right facility, with or without AI-based triage
• Financial risk management
• Medical case management.

Cost containment can come in many forms, said John, and insurers need to make sure they are covering all their bases – have direct contracts in key areas with key facilities, negotiate settlements at different levels for different medical claims costs, ensure there are several network options (national, regional etc), and ensure you are ready for complex claims management.

John then shared insights into the effect Covid-19 has had on patient care around the world, including delayed diagnosis and treatment of cancer and cardiac treatment, which has resulted in an increase in medical case costs as diseases have progressed further and need more complex care, as well as the psychological impact of the pandemic and the effect of Long Covid.

Dr Hayder Zubaidy, Chairman and Managing Director, Occucare Middle East

Dr Zubaidy began by saying that everyone in the room all has the same goals: patient safety, and fair costs. He then admitted that in almost every bill in a hospital, there will be ‘mistakes’ that are in reality overcharges from the facility. Covid has affected costs in hospitals, as it has resulted in an increase in overcharging and overbilling, so payers are now analysing bills from their providers more closely. How the process is managed locally, though, is key to managing the increasing costs.

The Dubai healthcare system, explained Dr Z, now works on a diagnosis related group (DRG) billing process, but this is a relatively new process for the system. The DRG billing process, though, is not applicable to everyone in the market – there are going to be two different systems for local payers and international ones – and this is where having a local partner can result in significant cost savings.

Surviving Covid, for Occucare, resulted in changes to the structure of the company and an increase in international partnerships instead of keeping staff on the payroll in different locations around the world. These partnerships have resulted in cost savings for payers. Partnerships and acquisitions, he said, are the new norm, and they allow companies to function effectively in a post-Covid world where hospitals are perhaps more likely to bill local providers differently.