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    Sreevidya Nair - Presentation

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    Ark Group
    Medibank is Australia's largest private health insurer covering 3.4 million people. Over 11.7 million Australians have private health insurance. In the year ending June 2011, private health insurers paid out $12.997 billion in benefits, with $9.71 billion for hospital treatment. The document discusses how the US Health Insurance Portability and Accountability Act of 1996 changed business processes for health insurers by requiring evaluation of procedures and an integration strategy. It concludes that health insurance requires reliable processes that can adapt to customer needs without impacting quality of care.

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    Sreevidya Nair - Presentation

    Uploaded by

    Ark Group
    115 views16 pages
    Medibank is Australia's largest private health insurer covering 3.4 million people. Over 11.7 million Australians have private health insurance. In the year ending June 2011, private health insurers paid out $12.997 billion in benefits, with $9.71 billion for hospital treatment. The document discusses how the US Health Insurance Portability and Accountability Act of 1996 changed business processes for health insurers by requiring evaluation of procedures and an integration strategy. It concludes that health insurance requires reliable processes that can adapt to customer needs without impacting quality of care.

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    Medibank is Australia's largest private health insurer covering 3.4 million people. Over 11.7 million Australians have private health insurance. In the year ending June 2011, private health insurers paid out $12.997 billion in benefits, with $9.71 billion for hospital treatment. The document discusses how the US Health Insurance Portability and Accountability Act of 1996 changed business processes for health insurers by requiring evaluation of procedures and an integration strategy. It concludes that health insurance requires reliable processes that can adapt to customer needs without impacting quality of care.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    115 views16 pages

    Sreevidya Nair - Presentation

    Uploaded by

    Ark Group
    Medibank is Australia's largest private health insurer covering 3.4 million people. Over 11.7 million Australians have private health insurance. In the year ending June 2011, private health insurers paid out $12.997 billion in benefits, with $9.71 billion for hospital treatment. The document discusses how the US Health Insurance Portability and Accountability Act of 1996 changed business processes for health insurers by requiring evaluation of procedures and an integration strategy. It concludes that health insurance requires reliable processes that can adapt to customer needs without impacting quality of care.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    Business Process Management Health Insurance

    Sreevidya Nair Group Lead, Business Systems, Medibank private

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    Outline

    About Medibank Health insurance in Australia Health insurance benefits paid last year Health industry interaction Business process, business drivers in health insurance Case study and findings Conclusion

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    About Medibank

    Australias largest private health insurer, incorporating the Medibank private and AHM health funds providing the largest provider network Integrated private health insurance and health service group Across our separate brands almost 3.4 million people are covered Operates over 100 stores and 50 clinics Australia wide Provider of occupational and travel health services to Government and corporate Australia

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    Health insurance in Australia

    Over 11.7 million Australians are covered by private health insurance Over 10 million Australians with Hospital Cover On 30 June 2010, 44.6% of the population, were covered by hospital treatment cover The most notable increase in coverage during the quarter was for people aged between 30 and 34. Notable decrease in coverage were seen for people aged 20 to 24

    Source: http://www.phiac.gov.au/resources/file/quarterlystatisti cs/Qtr%20Stats%20Mar11.pdf

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    Health Insurance benefits paid last year


    The total benefits paid by private health insurance funds for all types of hospital and general treatment services in the year ending June 2011 was $12.997 billion. Hospital treatment $9.71 billion, General treatment $3.22 billion Benefits paid increased across all category types, with hospital treatment benefits increasing by 8.1% and total benefits increasing by 7.8%.

    Source http://www.ahia.org.au/news/stats_and_data/private-health-benefits-paid-by-funds-phiac-june-2011/

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    Health industry participants


    Hospital Insurance Medicare Clinics Radiology services Pathology services Medical staff

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    Interaction

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    Business Process within Health insurance industry

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    High level business processes within health insurance

    Membership People and Culture Medicare transaction

    IT

    Provider details

    Claims entry

    Health Insurance Business process

    Health care codes and identifiers

    Manage Online Services

    Claims processing

    Sales & Marketing Preventive health

    Legal & compliance

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    Business drivers for Health insurance

    Accurately assessing and pricing risks of insuring a pool of people Securing competitive provider contacts and price Cost effective, technology driven administrative processes Exercising pricing power over small and mid size employers and individuals Getting rid of bad health risks whenever feasible

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    Case Study

    How a regulatory change in the US changed the Health Insurance and business process

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    HIPAA
    Health Insurance Portability and Accountability Act of 1996
    Title II

    Preventing Health Care Fraud and Abuse

    Administrative Simplification

    Medical Liability Reform

    Privacy Electronic Data Interchange

    Security
    Administrative Safeguards Physical Safeguards Technical Safeguards

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    Case study : HIPAA assessment

    The Client: A leading health insurance company in the United States was required to comply with the legislation of HIPAA standards in healthcare Scope : The client had an inorganic growth by acquiring smaller health insurance company resulting in membership and claims process being unique at each site More than 50 databases A number of interfaces and reports Very little process documentation 12 weeks AS- IS process assessment including maps and transaction flow Business Impact and technical document Remediation plan

    Timescale Deliverables

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    Summary of the findings and lessons learnt

    Unavailability of process documentation lead to manually documenting each and every AS IS process resulting in more time and effort Repeatable Process :Encourages cost effectiveness as the process can be used in future compliance related changes It is a business issue not an IT project Successful strategies start with the knowledge of system and impact of each change

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    Conclusion: Need for better business process in healthcare

    HIPAA became the catalyst for evaluation of antiquated business procedures as well as a catalyst for an integration strategy Process mapping allows us to identify productivity opportunities, best practices ,root causes of problems, create workflow and determine who owns what

    Healthcare industry demands reliable and secure transmission of sensitive data Healthcare Industry around the world is under tremendous pressure to reform and to improve the quality of care and service therefore the focus will shift on business process

    To conclude, health insurance is a very process intensive business and has to constantly adapt the growing needs of their customer without impacting the quality of care

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    Insert Picture Here

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    Thank you

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