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Sreevidya NairGroup Lead, Business Systems,Medibank private

Business ProcessManagement Health Insurance

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Outline

About Medibank

Health insurance in Australia

Health insurance benefits paid last year

Health industry interaction

Business process, business drivers in health insurance

Case study and findings

Conclusion

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About Medibank

Australias largest private health insurer, incorporating the Medibank private and AHMhealth funds providing the largest provider network

Integrated private health insurance and health service group

Across our separate brands almost 3.4 million people are covered

Operates over 100 stores and 50 clinics Australia wide

Provider of occupational and travel health services to Government and corporateAustralia

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Health insurance in Australia

Over 11.7 million Australians are covered byprivate health insurance

Over 10 million Australians with Hospital Cover

On 30 June 2010, 44.6% of the population,were covered by hospital treatment cover

The most notable increase in coverage duringthe quarter was for people aged between 30and 34.

Notable decrease in coverage were seen forpeople aged 20 to 24

Source: http://www.phiac.gov.au/resources/file/quarterlystatistics/Qtr%20Stats%20Mar11.pdf

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Health Insurance benefits paid last year

The total benefits paid by private health insurance funds for all types of hospital andgeneral treatment services in the year ending June 2011 was $12.997 billion.

Hospital treatment $9.71 billion,

General treatment $3.22 billion

Benefits paid increased across all category types, with hospital treatment benefits

increasing by 8.1% and total benefits increasing by 7.8%.

Source http://www.ahia.org.au/news/stats_and_data/private-health-benefits-paid-by-funds-phiac-june-2011/

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Health industry participants

Hospital

Insurance

Medicare

Clinics

Radiology services

Pathology services

Medical staff

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Interaction

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Business Processwithin Health insurance industry

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High level business processes within health insurance

People and

Culture

IT

Claims entry

Manage

Online Services

Sales & Marketing

Preventive health

Legal & compliance

Claims processing

Health care codes

and identifiers

Provider details

Medicare transaction

Membership

Health Insurance

Business process

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Business drivers for Health insurance

Accurately assessing and pricing risks of insuring a pool of people

Securing competitive provider contacts and price

Cost effective, technology driven administrative processes

Exercising pricing power over small and mid size employers and individuals

Getting rid of bad health risks whenever feasible

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Case Study

How a regulatory change in the US changedthe Health Insurance and business process

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HIPAAHIPAAHealth Insurance Portability and Accountability Act of 1996Health Insurance Portability and Accountability Act of 1996

Title II

Preventing Health Care

Fraud and Abuse

Administrative Simplification Medical Liability Reform

Security

Administrative Safeguards

Physical Safeguards

Technical Safeguards

Electronic DataInterchange

Privacy

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Case study : HIPAA assessment

The Client: A leading health insurance company in the United States was required to comply with thelegislation of HIPAA standards in healthcare

Scope :

The client had an inorganic growth by acquiring smaller health insurance companyresulting in membership and claims process being unique at each site

More than 50 databases

A number of interfaces and reports

Very little process documentation

Timescale

12 weeks

Deliverables

AS- IS process assessment including maps and transaction flow

Business Impact and technical document

Remediation plan

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Summary of the findings and lessons learnt

Unavailability of process documentation lead tomanually documenting each and every AS IS processresulting in more time and effort

Repeatable Process :Encourages cost effectiveness asthe process can be used in future compliance relatedchanges

It is a business issue not an IT project

Successful strategies start with the knowledge ofsystem and impact of each change

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Conclusion:Need for better business process in healthcare

HIPAA became the catalyst for evaluation of antiquated businessprocedures as well as a catalyst for an integration strategy

Process mapping allows us to identify productivityopportunities, best practices ,root causes of problems, createworkflow and determine who owns what

Healthcare industry demands reliable and secure transmission ofsensitive data

Healthcare Industry around the world is under tremendous pressure toreform and to improve the quality of care and service therefore thefocus will shift on business process

To conclude, health insurance is a very process intensivebusiness and has to constantly adapt the growing needs

of their customer without impacting the quality of care

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