7 Paying claims Flashcards
5 stages of claims process
- Visit to GP and contacting insurer for pre-authorisation
- Specialist determines and carries out required treatment
- Claim form and bills submitted to insurer
- Insurer processes claims
- Insurer pays provider and notifies customer
Reasons an insurer may refuse to authorise treatment
- Onset of condition started before policy
- Claim relates to a time before the policy began
- Treatment not likely to be effective
- Treatment previously has not been effective
Who monitors fairness of insurance policies?
FOS
Direct settlement agreements
Contracts with hospitals, where all costs are settled with the hospital on a regular basis
4 benefits of direct settlement
- No need for customer to arrange payment
- Customer knows hospital is covered
- Hospitals get paid quickly
- Insurers can obtain competitive rates
Downsides of direct settlement
- Claimants detached from cost control process
- Part payments
What happens if a patient has treatment for which they are not eligible or has not been pre-authorised?
The patient must pay
5 Advantages to electronic billing
- Faster process
- Data checks
- No paperwork
- Early notification of shortfalls
- Lower claims costs
Healthcode Ltd
The UK’s official medical bill clearing company
What does the insurer look at when assessing a claim?
- Benefit entitlement
- Previous claim history
Partnership consultants
Hospital consultants that adhere to insurer fee schedules
Eligibility checks
- Have all premiums been paid?
- Maximum limits?
- Exclusions?
- Underwriting
- Specialist eligibility
2 part of payment determination
- The amount of payment to be made
- To whom the payment should be made
Impairment codes
WHO ICD codes
OPCS
Office of population, Censuses and Surveys (or ONS)
CCSD codes
Clinical Coding and Schedule Development – over 2,000 procedures – each treatment given its own code
Consultant
Someone who holds a current NHS consultant contract
Session definition
A notional half day
QIPP abbreviation
Quality, Innovation, Productivity and Prevention initiative
Small value high frequency cash plan claims
Completion of a simple claim form and original receipt – heavily automated.
Known provider health cash plan claims payment
Claims may be paid directly to the supplier
Cash plan higher value claims payments
Automated payments, but with greater checking
Cash plan third party claim payments
Often wholly or partly handled by the third party
Dental insurance claims payments
Customer pays dentist and claims back from insurer
HICFG abbreviation
Health Insurance Counter Fraud Group (HICFG)
