Page 81 - MEDICAL AND HEALTH INSURANCE

MEDICAL AND HEALTH INSURANCE

 If it were to extend coverage for the dependants of the employees, then the

risk would be different, so the underwriter will have to evaluate the group

coverage for employees only or for dependants as well.

 In terms of a wellness program, many companies make an effort to create a
healthy workforce, out of their own initiative.

4.3.4 UTILISATION REVIEW

 A claims utilisation review is important to detect if reasonable and

customary charges are charged for medically necessary procedures to avoid

abuse or overcharging by providers. This can be done by the following

methods:

PRE-AUTHORISATION

In this method, the Insured is required to submit the details of the admitting

diagnosis or surgical procedures required, to the Insurer or their appointed Third-

Party Administrator for approval of the admission, prior to admission. This is usually
on a pre-planned basis, as a majority of the admissions are pre-planned with the

exception of a small probability due to emergency admission.

CASE MANAGEMENT

This usually applies to high-cost, complex treatment or major surgery and not to

common day-to-day cases. The case is managed, usually by the medical doctor of
the insurance company or their appointed Third-Party Administrator doctor, to

oversee that the treatment is delivered in the most cost-effective manner and in

accordance with good medical practice of the disability.

CONCURRENT REVIEW

The case is reviewed on an on-going basis as the patient receives treatment at the
hospital to ensure that he requires to be treated as an inpatient and all the

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