Design Element 6:

northcarolinasweekManagement

Nov 10, 2013 (3 years and 9 months ago)

94 views

Accra, Ghana

October 19
-
23, 200
9

Extending Health
Insurance:

How to Make It Work

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

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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

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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

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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

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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

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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

Social Health Insurance: Example
Organizational Structure:

Center for Medicare Services

11

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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

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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

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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

Example 1: Organizational
Structure for Health Insurance

Example 2 :Organizational
Structure for Health Insurance

Example 3 :Organizational
Structure for Health Insurance

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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

Accra, Ghana

October 19
-
23, 200
9

Extending Health
Insurance:

How to Make It Work

Thank you