The Insurance Process

1. The Insurance Process Hafez Atweh Provider Relations Manager

2. Agenda • Corporate Agreement. • Membership. • Hospital Agreement & Process. • Pre-authorization of Service. • Billing of Claims. • BUPA Internal Processing. • Reconciliation of Accounts.

3. BUPA World Wide • BUPA is a leading independent provider of health services: • SR 12.8 billion Turnover • Over 5 million members worldwide • Professional service to members and corporate management based on over 50 years of business experience • Ownership and management of over 600 facilities, including Hospitals, care homes, screening centers, close care retirement housing and health clubs • Employs more then 40,000 healthcare professionals • Leader in managed care in Australia, Spain and UK

4. BUPA Middle East • Operating in Saudi Arabia for 8 years • 14% Market Share with clients including NCB, Samba, SavolaMakshaff, Proctor & Gamble….etc • Nationwide hospital & clinic network • All services and insurance provided in the Kingdom • Operation Center in Jeddah, Sales & Service in Riyadh and Khobar • Employs more than 125 Healthcare Professionals • Tailored Service system to meet Customer’s needs

5. Mission To “Take care of the lives in our hands” as we provide a trusted and professional healthcare insurance service to customers,hospitals and clinics in the Kingdom.

6. Insurance Definition: • A contract that provides compensation for specific losses in exchange for a periodic payment. An individual contract is known as an insurance policy, and the periodic payment is known as an insurance premium. • A formal social device for reducing risk by transferring the risks of several individual entities to an insurer. The insurer agrees, for a consideration, to pay for the loss in the amount specified in the contract.

7. Visibility of Health Issues Data Available Known Issues & Cost Occupational Health PMI Ill-Health Retirements Litigation Sickness Absence Unknown Issues & Cost No Data Available Diet Occupational Risks Overweight Raised Blood Pressure Raised Cholesterol High Alcohol Usage Sedentary Lifestyle Smokers Stress Present But Not Reported, Measured or Costed

8. Hospitals Corporate Insurance Co. Patients

9. The Employer Needs: - Value for money. - Administration taken away. - Control over cost. - Healthcare partner. - Professionalism. - Improve performance by maximizing the people contribution.

10. The Employee Needs: - Accredited healthcare providers. - Improved customer services. - Better and more appropriate care. - Consistency and assurance. - Support when needed. - Care and prompt access to providers.

11. The Healthcare Providers Need: - Large number of patients. - Provide wide range of treatments. - Paid promptly for the services provided. - Good working relationships. - Good understanding of the benefits. - Resolve issues quickly.

12. Corporate Process: • Customer “ With a Need “. • Agree benefits and exclusions. • Agree Premiums. • Sign Agreement. • Notify providers. • Issue membership cards. • Distribute Information Pack. • Start provision of services.

13. Membership Cards:

14. Hospital Network • Hospitals & Polyclinics Network through out the Kingdom • Packaged pricing with written contract for Value & Control • Prompt payment settlement with providers • Standards - ICD10 coding • Educational and training workshops • Usage of quality accreditation standards • Direct settlement. • Unit cost and frequency monitor and control.

15. Pre-authorization of Services: • Outpatient services in excess of SR1000. • Inpatient Admissions. • Day case services. • Emergency services within 24 hours. • MRI & CT-scan. • Dental, Optical, and Maternity.

16. Monthly Claim Requirement: • Complete forms. • Eligible members. • Medical report. • Original invoices • Discount & Deductible collected. • Results of Lab & Rad. Investigations. • Group Summary • General Summary.

17. Discount & deductible on statement

18. Discount & deductible on invoice

19. Patient’s Contribution–Deductible: 1- Fixed Amount: SR20, SR10 2- Percentage: 10% O/P (Outpatient) 3- Nil. Deductible Should Be Collected From NetAmount Not FromGross.

20. In/Out-patient Claims

21. Claims Frequency - By Value

22. Clinical Coding • Standardized coding used - ICD 10 • Measurement means management • Management means standards and comparison • Performance means Quality of care and Cost effectiveness of care • Coding means consistent identification of Doctors and hospitals matched to resources used .

23. Hysterectomy Abdominal Q0740Hysterectomy and removal of adnexae Q0780 Day 4no cannulae / lines / catheters mobile full diet Discharge Criteria Day 5 • All symptoms controlled by oral medication • Baseline, BP, pulse and temperature( without antipyretics) • Normal diet for 24 hours • Passing urine and bowel movements for 12 hours • Balance of care lies with nursing staff/ care could be given safely • in alternate place of service • ADL and needs can be met with or without assistance • Patient has received instruction /education and follow up planning

24. Average LOS for Selected Doctors at Hospital X Surgical Inpatient Episodes (Aug 99 - Sep20) 7.0 6.0 5.0 4.0 Actual 3.0 2.0 1.0 0.0 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 Expected

25. Consultant Y 700 18 16 600 14 500 12 400 10 Number of Episodes 8 300 6 200 4 100 2 0 0 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Length of Stay Consultant BUPA Length of Stay Distribution W3710 - Total prosthetic replacement of hip joint

26. Breakdown of Medical Cases

27. Hospital Usage

28. Medical Costs - By Value

29. BUPA Claims Process:

30. Provider CCU E-claim Upload Claims Input Claims System Adjudication Medical Adjudication Technical & Medical QA Statement Payment

31. Our dedicated Customer Service lines HOTLINE 02 663 0505 TOLL FREE 800 244 0307 Emergency contact numbers available after normal working time Ready to serve you - Saturday to Thursday - 8AM to 9PM Customer Service - BUPA process Dedicated Customer Service call centre Our Customer Service team uses world-class call centre to answer all your queries

32. Thank you, Questions please