Page 95 - MEDICAL AND HEALTH INSURANCE

MEDICAL AND HEALTH INSURANCE

f) The claimant will have to pay the ineligible expenses incurred and the eligible

expenses would be paid by the insurance company.

Pre-authorization of claims have a differing impact on the patient and insurance
company, as follows: Impact on the patient:

 Delay in admission, especially when the information provided is not enough for

the insurance company to make a decision
 Delay in discharge, when time is required for the bills to be sent from the

hospital to the TPA and time taken to adjudicate the claim.

Impact on the insurance company:

 A means of costs containment to prevent abuse of admission, whereby day
care or outpatient treatment can be rendered. This has a great impact on the

claim utilization and the viability of the business

 Allows utilization management to be exercised on the current cases of
admission and not after discharge

 Loss of customers, if the service standards are not within the reasonable

acceptance time frames, especially on the time taken for authorization and

adjudication of claims.

5.3 SCHEME MANAGEMENT

Scheme management encompasses the administrative operational function of how

the scheme is to be managed in terms of delivery of the services and the expected

results of the scheme.

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