Accra, Ghana October 19-23, 200 9 Extending Health Insurance: How to Make It Work Design Element 7: Health Insurance Scheme Operations October 21, 2009.

Accra, Ghana October 19-23, 2009

Extending Health Insurance: How to Make It Work

Design Element 7: Health Insurance Scheme Operations

October 21, 2009

Objectives

Understand keys to operational success for Health Insurance schemes

Understand your organizations role in health insurance operations

Identify operational strengths and weaknessesUnderstand capacity building strategies

Key Considerations

Health insurance schemes have many organizational models

What is your role in each operational areaResponsible for the functionSupervisor of the function

Either as government regulator or contract administratorOrganization builder

Your Role in Operations

Responsible for FunctionE.G., You are responsible for contractingInternal SWOT type analysisIdentify GapsOrganizational Development planImplementation Plan

Your Role in Operations

Regulator or supervisor of function E.G., Insurance supervisor

Policies and regulations in place specific to health insuranceCapital requirementsReserve requirementsLicensing requirementsFinancial and other reporting requirements

Skill set for oversight of health insurance activitiesOversight of other types of organizations

TPAsHealth providersAgents and brokers

Your Role In Operations

Organization Builder (mentor)E.G., NGO, implementing organization, self-help group

Choice of organization (contracting)Capacity diagnosticTraining needs assessmentCapacity building programOTJ mentoringOutsource assistance

Key Operational Areas

Financial processes and managementContract managementMarketing and communicationsEnrollment and member servicesUtilization and quality managementPremium collectionsClaims managementInformation systems and monitoring

Financial Processes and Management

Budget systemPlanning and budgeting for revenues and expenses

Administrative, claims, marketing, legal, education costsRevenue estimates from all sourcesUsually an iterative process and may need adjustment

throughout a year

Budget ExecutionManagement of the flow of funds

Cash and asset management, internal controls , Accounts receivable and payable

Financial Information Management System

Page 9

Public Expenditure Management Overview

Budgeting Process

Macroeconomic

PolicyMacroeconomic

FrameworkBudgetCircular

BudgetProposals

ProposedBudget

Enacted Budget

FundsStructure

OrganicBudget Law

Revenue/ExpenditureProjections

Cash FlowForecasts

Financial Management

Processes

BudgetClassification

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Public Expenditure Management Overview

Financial Management Budget Execution Processes

FundRequests

Cash FlowForecasts

BudgetAuthorizationsto Ministries

BudgetRevisions

EnactedBudget

ExternalAudit

Cash & DebtManagement

General Ledger

Payroll/HRManagement

RevenueManagement

CommitmentAccounting

Procurement &Accounts Payable

Government FinancialManagement System

AssetManagement

Internal Audit

Contract Management

Many functions can be contracted outRisk bearing, claims processing, enrollment, premium

collection, education, ombudsman, provider paymentContracts should

Identify functional responsibilitiesBe enforceable under local lawsClearly state roles and responsibilities

Contract management skills requiredLegal, management, negotiation

Illustration of contract specifications

Marketing and Communications

Health insurance is not easy for people to understandEligibility, covered benefits, premiums, accepted

providers, exclusions, copayments, claims etc.Need to educate for

EnrollmentUse of benefitsDispute resolution

Marketing controls: role of regulationConsumer education: Techniques and skills

Enrollment and Contribution Collection

EnrollmentNeed strategies for getting people to join in voluntary scheme

Rwanda example: Incentives for CBHI leadership to achieve targets – community mobilization/pressure to join

Need unique identifier for obtaining servicesNot as easy as it sounds (same names, similar or no addresses)

Collections (how to collect and how to get to HI scheme)Depends on type: social contribution (tax); VAT; individual or

family premiumsHow to determine the amount of contribution (e.g., income and

family size variation)How to collect (particularly for the poor (both urban & rural)

Utilization and Quality Management

Focus on Utilization ManagementToo many and too few services are both problemsUtilization Review and Management

Utilization review - retrospectiveUtilization management - prospective

Case management

URAC defines utilization management as "the evaluation of the medical necessity, appropriateness and efficiency of the use of healthcare services, procedures and facilities under the provisions of the applicable health benefits plan."

Claims Processing

Can be most time consuming, slow and error-prone part of health insurance operations

Process of receiving claims, adjudication, payment, dispute resolution

Often the responsibility of TPACan be cashless or by reimbursementPaper or electronic systems (or both)Involves coding, eligibility determination, detection of

potential fraud, mapping to payment terms etc.

Group Exercise

ScenarioYour Health Insurance scheme will contract with:

Insurance companyAssumption of risk; coverage of acute care, contracting with

providers; provider payments Implementing organization (NGO)

Enrollment; premium collection; education and outreach; primary care; ombudsman

TaskIdentify key elements that need to be in Request for

Proposals for each entity to permit you to evaluate and choose the best organizations

Accra, Ghana October 19-23, 2009

Extending Health Insurance: How to Make It Work

Thank you

Slide Title

ObjectivesBullet two

Bullet threeBullet four