scholarly journals Claim Settlement: The Moment of Truth in Health Insurance

2019 ◽  
Vol 8 (2) ◽  
pp. 581-585
Keyword(s):  
Health Insurance ◽  
The Other ◽  
Health Insurance Company ◽  
Insurance Company ◽  
Settlement System ◽  
Medical Expenses ◽  
Health Insurance Market ◽  
Insurance Penetration ◽  
The Moment ◽  
Very High

A customer centric claim settlement system goes a long way in mitigating the anxiety of patients. At the time of buying Health Insurance, a customer is assured that the Health Insurance Company (HIC) will take care of the medical expenses, in case of his hospitalization. But when such an eventuality happens, many times HICs go back on their words based on procedural non-compliance or because of some conditions written in fine prints. Therefore, how HICs respond to the financial needs of the patients during the claim settlement is the real Moment of Truth. Failure on the part of the HICs in honoring their commitment leads to high Out of Pocket (OOP) Expenses and acute financial hardship to the patients. This article is important primarily because a customer always has an apprehension about the claim settlement. Hurdles one faces during claim settlement is a big contributor to the low customer satisfaction (LCS) which in turn contributes to poor Health Insurance penetration. On the other hand, false, ineligible and inflated claims adversely affect the business model of HICs. The article also highlights why the Incurred Claim Ratio (ICR) in Health Insurance is very high in India and why this has become a roadblock towards expansion of Health Insurance Market (HIM).

PMU20 Burden of Disease in Young Population of a Colombian Health Insurance Company

2021 ◽  
Vol 24 ◽  
pp. S148
Author(s):  
Sotomayor M Carrasquilla ◽  
N. Alvis-Zakzuk ◽  
Mejía F Salcedo ◽  
L. Moyano ◽  
N.R. Alvis-Zakzuk ◽  
...  
Keyword(s):  
Health Insurance ◽  
Burden Of Disease ◽  
Health Insurance Company ◽  
Insurance Company ◽  
Young Population

Medications requiring prior authorization across health insurance plans

2020 ◽  
Vol 77 (8) ◽  
pp. 644-648
Author(s):  
Laney K Jones ◽  
Ilene G Ladd ◽  
Michael R Gionfriddo ◽  
Christina Gregor ◽  
Michael A Evans ◽  
...  
Keyword(s):  
Health Insurance ◽  
External Factors ◽  
Insurance Companies ◽  
Health Insurance Company ◽  
Prior Authorization ◽  
Insurance Company ◽  
Insurance Plan ◽  
Narcotic Analgesics ◽  
Health Insurance Companies ◽  
Effective Use

Abstract Objective To determine the amount of variation in numbers and types of medications requiring prior authorization (PA) by insurance plan and type. Methods Most health insurance companies require PA for medications to ensure safe and effective use and contain costs. We generated 4 lists of medications that required PA during 2017 for commercial, marketplace, Medicaid, and Medicare plans. We aggregated medications according to the generic medication name equivalent using codes and medication names. We compared these medications to assess how many of the medications required PA by 1, 2, 3, or all 4 of the insurance plans. We counted all prescription orders written for a patient age 18 years or older with health plan insurance during 2017 for any of the medications that appeared on the health plan’s PA lists by querying the electronic health record. Results PA was required for 600 unique medications in 2017 across the 4 plans. Of 691,457 prescription orders written for 114,159 members, 31,631 (5%) were written for 1 of the 600 medications that required PA by at least 1 insurance plan. There were 12,540 medication orders (written for 6,642 members) that potentially required PA. The marketplace plan required PA for the greatest number of medications (440), followed by the Medicare (272), commercial (271), and Medicaid (72) plans. The most commonly prescribed classes of medications for which PA was required by at least 1 plan were antihyperlipidemics (22% of orders potentially requiring PA), narcotic analgesics (13%), hypnotics (12%), antidiabetic medications (9%), and antidepressants (9%). For only 25% of medications (151 of 600) was PA required by at least 3 plans, and for only 5% (32 of 600) was PA required by all 4 insurance types. Conclusion Medications requiring PA can differ within a single health insurance company, but this variation may be unavoidable due to external factors.

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