MR Microinsurance_2012_03_29.indd - International Labour ...

152 Health insurance
Box 6.8 Th e claims administration function
In 2009, Microcare restructured its 12-person claims administration team into
fi ve units. Each administrative unit fulfi lled lled a a distinct function to improve effi -
ciency:
1) Invoicing: claims were matched to healthcare provider invoices (sent often in
batches). Discrepancies were sent to the investigation unit.
2) Data entry: data from paper claims were entered into the computerized data-
base. Th e system automatically alerted Microcare staff when charges for key
services and drugs exceeded acceptable limits. A query was made to validate
the appropriateness of the charge.
3) Data analysis: a medical doctor reviewed the appropriateness of the diagno-
sis and corresponding treatment, and a drug specialist checked prices and
benefi ts allowed for drugs to identify possible occurrences of fraud or inap-
propriate billing. Questionable claims were queried further; approved claims
were sent to reporting so that questionable claims did not delay an entire
batch associated with an invoice.
4) Investigation: administrators followed up with healthcare providers to
resolve questions on claims (e.g. missing or inconsistent information, unex-
plained charges).
5) Reporting: approved claims were sent to a supervisor for a fi nal review and
approval, which triggered a request to the accounts department to issue payment.
Source: Authors.
With capitation, the HMI scheme pays a fi xed amount per insured person
assigned to a healthcare provider. A per capita payment approach can be quite
simple when enrolment information is accurate, timely and fi xed for a longer
period. Capitation payments become complex to administer when a scheme permits
open enrolment, or when retroactive adjustments due to delayed or incorrect
enrolment data are required. Capitation can be more diffi cult to administer
if the per capita payments are made more frequently (e.g. monthly), and when
payments by members vary depending on factors such as age, gender or location
(GRET-SKY, CBHI – see Box 6.3). Additional challenges can arise relating to premium
collection and policy administration. For example, a waiting period may
be mandatory to reduce adverse selection, requiring the scheme to defer capitation
payments until the waiting period has elapsed; or a grace period may apply
for unpaid premium before a policy is cancelled, making it diffi cult for the HMI
scheme to make payments (see Box 6.9). As these complexities occur and schemes
scale up, they will need better MIS.