Student Dissertation

Agency : Denial Rate, Turnaround Time, Mediclaims, Health Insurance

Objective : • To identify the reasons behind high turnaround time and rejection of mediclaim in GMC Hospital • To identify the policy level ambiguities leading to high mediclaim rejection • To suggest measures to reduce turnaround time and rejection rate of mediclaims in GMC Hospital

Background :

Methodology : For the purpose of study, primary data was collected through Daily approval request tracker to track the number of approval requests received, their average turnaround time and rejection rate. Secondary data was collected through Receipt settlement summary report from finance department for data of latest five months rejection rate and through reconciliation platform for the reasons of rejections. A detailed Value Stream Mapping was prepared to mark all the value added and non value added process, value added and non value added time was noted.

Findings : After analyzing turnaround time, rejection rate, reasons of rejection and common causes for high turnaround time and rejection rate recommendations were made for Process improvement through Upgrading HMIS, Manpower planning and Insurance department redesigning. Result of which, the turnaround time can be reduced to 1/4th and the rejection rate can be reduced to 1/2.

Recommendations : Turnaround time and rejection rate are the important measures for insurance department in a hospital. As per IRDA any hospital having rejection rate less than 2% is considered to have good practice of claim process management. Hence hospitals having high turnaround time and rejection rate should work on process improvement. Standards of health care are considered to be generally high in the United Arab Emirates, Compulsory health insurance is emerging in UAE. Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care and health system expenses among targeted group, an insurer can develop a routine finance structure Health Insurance works based on mainly two types of policies • Group policies • Individual policies There are four major players in Health Insurance system • Payer • Provider • Insured • TPA A health care provider is an individual or an institution that provides preventive, curative, promotional or rehabilitative care services. Hospital has a dedicated department to offer quality and affordable specialized superior medical care to the members of most of the insurance companies through Insurance department. Many times patients have to pay out of pocket in spite of having health insurance coverage due to the rigid process followed by the healthcare provider to take approval from insurer. When the claim process is rigid, many times it ends up with increased turnaround time and high denial rate leading to decreased efficiency of provider. Hence planning the process is very necessary in order to fight the above said challenges. Aim of the study: • To reduce turnaround time • To decrease rejection rate • To smoothen the approval process • To increase efficiency