What is the most important factor in the Health care process?
The most important factor in the Healthcare process is the claims part and its explained as follows:
The insured can approach the insurance company directly himself or in cases of no money return reimbursements, the hospital will approach the insurance company on his behalf.
The claims executive will then check the bills and claims from the insured/hospital to see if the benefits are covered for or there are areas on which he is not covered for. If the claim is eligible, then the payout amount is calculated based on what he is eligible for and what he has filed in. This payout amount will be forwarded to the Finance department for a final payout via any chosen method.
As a business Analyst, elaborate on the Health care Claims process?
There are several types of Healthcare claims which can be claimed under healthcare products. The benefits are:
: Outpatient / General Practitioner (GP) care – GP would look into patient’s primary care benefits and they could also refer the patient to a more specific doctor and/or hospital when special treatment is needed.
: Inpatient / Hospitalization during surgery – GP could introduce the patient to an approved hospital. The hospital care includes in-patient treatment and day surgery in the hospital.
: Dental – Dental covers dental issues like capping, crowning, polishing, etc.
: Maternity – This covers the benefits of surgery for birth, miscarriage, etc
An insured could choose which benefits he wants to cover according to the type of health insurance he has taken. These benefits are renewable after one year period of time.
What are the methods by which detection of fraud can be done in healthcare claims from the system’s perspective?
With uniqueness of each healthcare claim being maintained intra insurer as well as inter insurance companies can go a long way in identifying claim frauds. If the systems can detect the same parameters for the claim as has been done previously , then the fraud can be stopped. The parameters can be hospital bill number, the date of hospitalization or the amount being claimed etc.