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Design Element 6: Health Insurance Scheme Organizational Structure

Design Element 6: Health Insurance Scheme Organizational Structure. Objectives. By the end of this session, participants will be able to: Understand the functions necessary for health insurance administration

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Design Element 6: Health Insurance Scheme Organizational Structure

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  1. Design Element 6: Health Insurance Scheme Organizational Structure

  2. Objectives By the end of this session, participants will be able to: • Understand the functions necessary for health insurance administration • Understand the varying models of setting up the organizational structure for health insurance management • Identify critical organizational characteristics that will help health insurance flourish

  3. Organizational Structure Overview • Focus on functions and organizational arrangements • Not execution of functions • Range of operational functions common to health insurance schemes • Common from community-based to national schemes • Diverse organizations can be involved • Some functions split between organizations • Some functions required of multiple organizations

  4. Organizational Structure Overview (2) • The challenge is allocating the functions to different organizations such that • All functions are accounted for • Functions fit with the strengths of each organization • Incentives for each organization are aligned with goals • Lines of authority and accountability are clearly articulated and understood • Financial flows are clearly defined

  5. Footer Core Functions of Health Insurance Schemes • Core Functions • Governance and management • Provider Services • Consumer Services • Actuarial and Risk Management • Clinical standards and Quality Assurance • Financial management

  6. Footer Governance and management (two different functions) • Governance: integrity and performance of organization • Appointment and oversight of senior management • Internal controls (audit committee etc.) • Compensation • Public Affairs • Stakeholders relations • Management: Day-to-day operations • Human resources • Legal • Financial management • Program execution • Communications • Information technology

  7. Footer Core Functions Explained • Provider Services • Selecting and contracting with health care providers • Determining payment types • Claims processing and adjudication • Provider payments • Fraud and abuse • Provider relations and communications • Consumer Services • Enrollment • Education (development and dissemination) • Ombudsman and consumer complaints • Reimbursement (if not cashless system)

  8. Footer Core Functions Explained • Actuarial and Risk Management • Costing and pricing • Premiums • Underwriting • Financial requirements • Utilization analysis • Clinical Standards and quality Assurance • QA program • Performance standards • Prior authorization • Clinical and quality standards for provider contracting • Utilization review • Consumer feedback • Reporting systems

  9. Footer Core Functions Explained • Financial Management • Office of Chief Financial officer • Contribution collection (all sources) • Budgeting • Budget execution (financial controls, audit, chart of accounts) • Cash and asset management • Accounts Payable (e.g., claims) • Accounts Receivable (other than contributions) • Financial reporting • Interactions with office of the Actuary

  10. Social Health Insurance: Example Organizational Structure:Center for Medicare Services

  11. Footer Community-based schemes • How could a small community-based health insurance scheme carry out the various functions described? • Governance and management • Provider services • Customer services • Quality assurance and clinical standards • Actuarial and risk management • Financial management

  12. Footer Organizations Involved in Health Insurance Functions • Ministry of Finance • Ministry of Health (national, regional or local) • National (or Regional) Health Fund • Other ministries (labor, defense) • Insurance regulator • Insurance companies • Managed care organizations • Networked Health plans (e.g., hospital networks) • Third party Administrators • Quality assurance and accreditation organizations • NGO, FBO and other intermediaries • Provider Associations • Agents and brokers

  13. Footer Health Insurance Scheme Organizational Options • Wide variety of models • Depends on • Sponsor (e.g., government (what level) or market) • Goals • Financing • Specific barriers to be overcome • Target population • Benefit package • Key is that all functions are covered, there is clarity of roles and responsibilities, incentives are aligned

  14. Example 1: Organizational Structure for Health Insurance

  15. Example 2 :Organizational Structure for Health Insurance

  16. Example 3 :Organizational Structure for Health Insurance

  17. Footer Health Insurance Scheme Organizational: Exercise • Handout • Each table discuss the task • Develop a list of pros and cons (incentives) for each model • Group forum to discuss

  18. Thank you

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