Student Dissertation

Agency : Basic Health Plan; Participatory Insurers; Dubai Health Authority; Agreed Tariff

Objective : To assess the functioning of various departments with respect to the standard working processes and to understand the status of claims in TPA.

Background : The study focused on the basic health system of UAE with main focus on Dubai. Under the new Health Insurance Law, health insurance was compulsory for all 9 residents of, and visitors to, the Emirate of Dubai including all the free zones within the Emirate. It was permissible for insurers to provide enhanced cover over and above the DHA Health Plan. Only Participating Insurers were permitted to provide the Basic Health Plan which was mandatory by governing body of Dubai. Regulatory bodies were for controlling premiums and TPA was for controlling the cost of the treatments. TPA and insurance company’s together work for better utilisation of premiums collected. Claims processing is an important step which affects the performance of a TPA and insurance company indirectly.

Methodology : Study design was descriptive to understand the process flow, study reasons for rejection, types of cases, claims from each network and different types of diagnosis. Both Primary and secondary data was collected. Primary data was collected through observation, interviews and discussions with staff to understand the process flow and the complaints they receive from the providers and patients. Secondary data was collected through existing MIS/Toshfa utilization; reports from 15th October to 31st March were downloaded to find out the number of claims under each category. 500 claim forms were selected on convenient basis during processing to find the disease burden. Type of data was quantitative. Data tool for understanding the process, reasons for rejection and complaints was observation of the steps and discussions with staff. For status of claims, data from MIS and selected files was taken. Data collected was number of OP and IP cases, number of claims from each network, reasons for rejection of claims, types of cases under OP, number of claims from each category of diagnosis.

Findings : It was found that number of OPD claims were higher than IPD claims. Majority of cases were basic types. Under disease burden, respiratory cases and digestive system disorders were high. GMC group of hospitals cover majority of patients. Major reason for rejection of claims was providers not following agreed tariff. E-referral, E-prescription, E-claims, E-approvals (PBM) was to fasten the process and keep control on providers and TPA. Overutilization of services was checked as co-payment was per encounter of services basis. Premium was fixed for basic plans which control the high premium taken from insurance company. Base agreed tariff prevented cost escalation from provider’s side. Different networks for different income strata of people depending on premium, co-payments and annual limits so that cost was justified accordingly.