Case Study On Corporate Health Insurance
Introduction
A large service sector company with around 30,000 employees spread across multiple group businesses and multiple locations was experiencing inconsistent experiences with healthcare benefits. The premiums they paid and the benefits they extended to the employees differed across locations, as well as the partners that the individual businesses selected, offering them little solace at the time of hospitalization. The brokers that were selected helped the company to place the business with an insurer but had no experience and vision to service the account consistently at the time of claim. The Third Party Administrators servicing the account, who were responsible on behalf of the insurance companies to provide claims validation, health insurance identification cards, organizing cashless network arrangements with hospitals, etc., were selected arbitrarily and without negotiating service levels and turnaround time agreements. Employees often experienced pain points during cashless treatment with long waits at the hospitals. The respective HR SPOCs were also under pressure often due to slip-ups in data gathering and sharing with the insurance company, themselves having no knowledge of the implications of various nuances of health insurance. Many times, the new employees were not enrolled in the policy, and their dependents ended up in the hospital only to find that the benefits could not be availed due to a lack of endorsed data with the insurance company and the TPA. HR SPOCs braced themselves against employee ire, especially during employee forums, and stories of apathy of the organization during trying times for an employee were common.
Initial Intervention
About a year and a half ago, we visited one of the units of the company and started helping them to manage the healthcare and health insurance benefits of a small but senior group of about 600 employees. During this period, we took the opportunity to study the organization's benefits in insurance as a whole and recommended that the client should consolidate the health insurance portfolio on a pan-India basis to extend a seamless and single experience to the employees, along with centralizing the data collection and information dissemination. Our exercise spread over three months resulted in a shared services model for the company and eventually fit in well with client organization structuring since they too shortly moved onto the shared services platform.
Implementation of a Single Policy
As part of the solution, we implemented a single policy in the organization with the same benefit structures, which incidentally are some of the best in the country, including maternity for Rs. 60,0000, coverage of all pre-existing ailments, waiver of all standard exclusions, and a critical illness cover to double the sum insured in case of 10 ailments including cardiac, neurological, and severe trauma cases. Other exclusions like cosmetic surgery, OPD treatment exclusion, and the spirit of the coverage under health insurance are clearly defined and communicated to all. Dental treatment, though covered last year, has been removed this year, and treatment of AIDS has not been covered (though in the US Embassy policy issued by the same insurer, it is covered and therefore it can get covered). The process for reimbursement claims is also clearly defined, and a turnaround time of 15 days has been laid down for 90% of the cases. In case the documents submitted are deficient, the same needs to be communicated to the employees by the TPA within 10 days. What is also covered is 30 days pre-hospitalization expenses on an outpatient basis and 60 days post-discharge expenses. These are to be filed separately as reimbursements and cover the cost of drugs, investigations, and doctor consults.
Employee Involvement and Data Collection
Interestingly, the employees in the company decide their own sum insured after the organization has negotiated with the insurer, and therefore the data collection exercise is done annually with the employees, and often there are changes in sum insured, substituting coverage of parents with parents-in-law, etc. We set up centralized collection of employee data through our web-based model. Once the employee logs into her account, she can see the detailed benefit chart, premium rates, policy terms, FAQs, etc., and she can fill in her family details. Once she submits the details, an automatic email is sent to her with the same details for her records and as a confirmation of her data being added. This mail also has three attachments containing policy terms, salient features, and a process flow chart with an escalation matrix. The portal is open for new joiners for 15 days every month to add their data.
System and Process Improvements
Clearly, well-documented systems have been set up, TPA selected, and service levels agreed to and communicated. Processes have been set up to track the performance of all parties, including the TPA and ourselves. We become the single point of contact for all information and actions, whether to do with information sharing, coordinating with the TPA/Hospital, and the HR. We have implemented a trouble ticket system with auto-escalation up to four levels to track internal and external SLAs. We are hosting a knowledge base on our website to share various issues and implementing a strong feedback system for all interventions to track the quality of service and the experience of customers. All these processes are shared transparently and in real time with the client SPOC.
Medical Assistance and Support
We realized early on that coordination of health insurance benefits is just a hygiene factor. What is more critical to the employees is not only taking care of their operational issues with compassion during such times but also they require strong support in terms of medical assistance. Our medical wing, comprising full-time doctors, has created a huge knowledge base on ailments and their treatment, especially home treatment for minor ailments and the dos and don'ts for critical ones, including post-hospitalization recovery processes, generally an overlooked area even for treating doctors. We understand that healthcare is a low-involvement area for most people until there is a need to go to a doctor. At such times, often individuals rely on word of mouth and unreliable sources for their choice of doctors. We, with our industry experience, understand the need for such reliable and timely information, viz., which gynecologist is better known for more normal deliveries than surgical and which ones may be good for uterine cysts. Similarly, doctors based on specialty, experience, good peer review, etc., have been compiled along with their personal contact details. Quite often, we provide solicited recommendations on good doctors in the country and go a step ahead to fix appointments and ensure that the employee has an experience of someone on her side during such times. Our doctors interpret clinical findings of the treating doctor, translating them into layman's language to explain to the family what the condition is and what the treatment options are. We at times do specific research in finding the best-in-class treatment across the world in critical cases, organize second opinions in such cases from other leading doctors across the country. We have classified critical cases internally, which get tagged for extra care. These critical cases are of two types: the ailment being critical or the employee being critical in the organization (Hay's principle). In such cases, we often are present in the hospital at such times as required. This gives employees an amazing experience and also communicates the organization's concerns for their well-being and importance to the company.
Monitoring and Proactive Health Management
For our client organization, our in-house doctor implant is helping understand the trends in the morbidity pattern within the company during working hours. We are now analyzing data of the past few months and looking at the loss for the client due to sickness and its impact on the company. Regular seminars with defined outcomes are being conducted to proactively manage the welfare of the employees, including alternative therapies like yoga, pranic healing, etc.
Our various initiatives with this client have earned us the nickname of Munna Bhai, and we are happy to be known that way.