Insurance companies today are faced with the rising risk profile of members and the increasing cost of hospitalization and care. This directly affects the claim ratio and profitability of insurance providers. Ageing population—the elderly are expected to make up more than 20% of the ASEAN population, which is higher than the world average of 16%. Rising hospitalization costs due to increased use of Emergency (ER), readmission and avoidable hospitalizations.
Technology advancements and the pervasive use of mobile technology have opened up new opportunities to manage and contain risk. Segmentation of members by risk profile — Using a combination of clinical analytics, demographic profiling and health risk assessments (HRA) to quantify risk.Intervention programs and methods that are adaptable based on risk profiles and specific conditions such as diabetes, hypertension and obesity.
Home care has gained importance in the past few years because of the growing aged population and the rising costs associated with eldercare. By 2050, 1/5 of the world’s population will be aged 60 or over, and 80% of the world’s aged will be in developing countries.Rising Costs of Providing Care — Burgeoning costs associated with increasing healthcare needs and pricing pressures.Staff Productivity — Need for smarter solutions for simplified and automated processes to boost staff productivity and reduce safety risks. We create contract classification codes that actually are attached to the contracts to pay out the claims. We perform contract set up by creating the contract templates for both par and non-par providers. We download all kinds of fee schedules / modifiers from CMS and perform maintenance. We create all kinds of provider contracts and attach appropriate Benefit categories and fee schedules. We are providing data scrubbing and member demographics loading into software. We also verify data on government works portal. Our service includes posting daily enrollments files to CMS, receiving and taking action on the TRR files. We also work on disenrollment. Most HMOs require patients to get a referral from their Primary care Physician before seeing a specialist. Our services include receiving and creating the authorizations for referral requests in all forms (fax, email, telephone). We ensure loading the referrals and authorizations into designated software periodically.