Page 96 - MEDICAL AND HEALTH INSURANCE

MEDICAL AND HEALTH INSURANCE

5.3.1 BASIC PRINCIPLES OF SCHEME MANAGEMENT AND ADMINISTRATION

The administration of the scheme establishes the rules and procedures of how a
scheme is to be managed. It will generally take into account the following:

 Setting up of parameters of the plan and structure

 Process flow of documentation and manuals

 Avenue for grievances

 Data upkeep
 Provider network record

 Regulatory fee schedule

 Admission and discharge procedural flow
 Criteria of change permissible for policy conditions

 Claims processing.

Generally, it would be taken care of by a good management information system that

automates many of the administrative functions.

For such a wide role and functions, insurance company appoint a Chief Medical
Officer (CMO) who is responsible for the overall scheme management. The

administrative role of the CM0 includes the following:

 Training and advising underwriters and claim officers
 Underwriting complex cases of proposals

 Adjudicating complex cases of claims

 Resolving disputes with consultants

 Analyzing trends and claims patterns

 Advising on potential new trends or new medical technologies development.

CMOs are usually qualified medical professionals who may work full time with the

insurance company or may be consultants to the insurance company.

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