Many medical professionals are now getting in healthcare sector and making their way to high peaks. Health insurance is emerging as the most important segment in the insurance sector. Medical professionals play a vital role in various areas in health insurance companies like; verification of claim payments against health insurance coverage, medical underwriting of the proposals before its acceptance, investigating the fraudulent claims, empaneling of hospitals & diagnostic centres etc.
Scope for Medical Professionals in Insurance companies & TPA’s:
The scope is very clear, health professionals who have better communication skills, soft skills to handle computers & software’s and interaction power will definitely grow in industry. Candidates who wish to learn & evolve can easily earn good salary at the beginning & there is no limit for the growth. Advancement in career is totally based on the individuals capability to perform & take himself to next level.
Career guide: – How Medical professionals can become health insurance experts: There is no specific certification on medical underwriting/claim processing/health claim investigator or for hospital relationship manager; however the medical professionals with handy experience are selected for these jobs with specific experience in such fields either from TPA’s (Third party administrators) or from Insurance companies.
Steps to become a health Insurance expert: The initial requirement to become a health insurance professional is to graduate from a bachelor’s degree program (MBBS/BDS/BAMS/BHMS). The next step is to begin working in Insurance companies or TPA’s. Few TPA’s offer fresher’s claim processor jobs for the medical professionals. Third Party Administrators popularly called as TPA’s are important employers in insurance sectors who are engaged by Insurance companies for certain percent of fees to act as service providers on their behalf. These TPA’s provide intensive on job training to the medical professionals along with training on soft skills required to understand the IT systems & software’s involved in claim processing. Post trainings, medical professionals are deployed on various roles like reimbursement claim processing, cashless claim processing or in Authorization team. After gaining a good experience in such roles, medical professionals can move out in hunt of various jobs either in Insurance companies or in other TPA’s.
Next & important step is to advance career with industry certifications. While certification is not required to work in the field, many employers prefer or seek candidates who are certified. The Insurance Institute of India serves the purpose of promoting Insurance Education & Training in the country. Insurance institute of India conducts examinations in insurance theory and practice and related subjects for awarding certificates, diplomas and degrees to those interested in insurance. Licentiate, Associate & Fellowship examination are conducted by institute twice in a year. Interested candidates can enroll & pass the examinations to get the certificates by selecting relevant subjects. Institute also offers specialized Health insurance diploma.
To get started, it is important to understand important terms in Health insurance;
Let us understand the term, “Claim processing / Claim processor”.
In Health Insurance, claim process initiates at the time of hospital admission for Cashless admission or while filing a reimbursement claim for medical expenses incurred at a non-networked hospital. In India, General and Health insurance companies are tied-up with hospitals across the country to offer cashless benefit to their customers for any medical emergencies. Mediclaim processors are trained on the policy Terms & conditions on the basis of which claim is processed. Please refer the link to know the complete details: Know-how of Health Cashless and Reimbursement Process.
There are many fresher’s jobs available for medical professionals as the claims processor who can come on board of Insurance Companies & TPA’s with initial trainings provided to analyze and process the insurance claims, checking it for validity & approval/rejection. Health claims processor is an entry-level job that includes on-the-job training. Those with a medical background have good job opportunities for these positions. As medical professionals are deputed in the role of claims processors it is expected from such resources to have an extensive knowledge of medical terminologies while the experience of using computer is also mandated. It is important for medical claims processors to assess the medical documents correctly in order to be in position to approve or deny payments to the hospitals. Good communication skills further add to hassle free claim settlements. Claims are to be thoroughly reviewed to ensure no checks are missed, both on medical & policy part.
Job Responsibilities/Job Duties of Health claim processor:
- To serve medical insurance customers by determining insurance coverage; examining and resolving medical claims; documenting actions; maintaining quality customer services; ensuring legal compliance.
- To determine covered medical insurance losses by studying provisions of Health Insurance policy.
- To establish proof of claim by studying medical documents; to assemble additional information as required from outside sources, including claimant, physician, employer, hospital, and other insurance companies; initiating or conducting investigation of questionable claims.
- To documents medical claims actions by completing forms, reports, logs, and records.
- To resolve medical claims by approving or denying documentation; calculating benefit due; initiating payment or composing denial letter.
- To maintain quality customer services by following customer service practices; responding to customer inquiries and queries.
- To protect operations by keeping claims information confidential.
Let us understand the term, “Medical Underwriting”.
Medical underwriting is the term used by Life, General & Health Insurance companies that refers to the use of medical information to evaluate an application before providing the health insurance coverage. Mediclaim policies are usually designed to provide coverage for unfortunate event of hospitalization in case of deranged health conditions mostly new and acute, previously not known to the person seeking insurance policy. It would be apt to mention the term, “Pre-existing” here. It is the disease condition prevailing before opting for health insurance coverage. Medical underwriting process is set by the Insurance companies to decide, based on the medical history, whether to take the application for insurance or not. Based on the underwriting decisions, waiting periods for pre-existing conditions are decided. Usually, coverage for pre-existing conditions begins from 4th or 5th year of the policy. Depending upon the severity of the condition, proposal is either accepted with or without waiting periods or rejected by the medical underwriters. Further, after accessing the medical reports, medical underwriter either applies permanent exclusion for the specific conditions or applies loading on the premium to be charged. On acceptance of the underwriting decisions by customers, policy is issued and comes into force.
Being expert & good understanding of medical terminologies, health professionals (Doctors) are in great demand for these jobs. Updating knowledge in insurance domain along with professional certifications provides great profile for medical underwriting jobs in insurance sector.
Job Responsibilities/Job Duties of Health Underwriter:
- Analyze information in insurance applications by gathering and preparing preliminary clinical and medical analysis based on information provided in proposal forms.
- Determine the risk of insuring a client.
- Screen applicants on the basis of medical reports.
- Evaluate recommendations from underwriting software.
- To be in continuous coordination with sales team to obtain details information from customers.
- Decide whether to offer insurance or decline.
- Determine appropriate premiums and amounts of coverage.
Let us understand the term, “Fraud & investigation”.
The role health claim investigator is to curb the frauds. Fraud involves intentional misrepresentation of information. Health claim investigators play a key role given that they spend more time perusing through a wide variety of documents. Claim investigators suspect the documentations not to be genuine inform a claims department of TPA’s/Insurance companies to verify the information.
Health professionals; practicing doctors & para medics are utilized by many insurance companies for field investigations/fraud detection of claims. Such professionals can take up the part time job opportunity by working as health claim investigator without hampering their present work.
Job Responsibilities/Job Duties of Health claim investigator:
- Fraud detection through hospital & home visits.
- To coordinate with the internal claims team.
- To complete the allocated cases within decided and agreed turn around time.
- To Maintain the Confidentiality of the Reports & the data related to the Cases assigned.
- To ensure faster in time recovery of all pay & recovery cases with minimum expenses to optimize claims cost saving / recovery revenues.
- To maintain the recovery process in coordination with external collection agencies
- To appoint new collection agencies for recovery
- To plan field visits for the high values cases for recovery
- To work in close coordination with Legal / Claims team
- Professional fees of vendors to be processed
- To analyse, identify trends and provide reports to management as necessary
Let us understand the term, “Provider networking”.
Provider networks are groups of health delivery systems that have service level agreements with Third party administrators and Insurance companies to provide health care facilities to insurance customers. Network providers not only includes tied up Primary, secondary & tertiary care hospitals for providing cashless claim service to insurance customers but also includes; physicians, specialists, surgeons, diagnostic labs, radiology centres, home health services, nursing care, physiotherapist, chemists and more. Insurance companies enter into tie-ups with network providers to ensure their customers get access to quality health care at discounted prices. Insurance companies draft, review, negotiate, and finalize all contracts with all healthcare providers in the network & extend the value added services to their customers.
Career Opportunity: –
Networking is an excellent field of interest for health professional to work in health insurance sector. There are ample of job openings specific for health professionals in country. Working as hospital relationship manager or Networks manager of TPA’s or Insurance companies requires excellent interpersonal skills to effectively communicate all contractual processes. Writing skills are importance to draft the contracts/agreements to enroll the health care service center on the panel of insurance companies further ensuring timely renewals. Having knowledge of medical terminology is must along with negotiation abilities to only establish profitable working relationships with network centres. Travel could be required most of the time for visiting and meeting with healthcare providers.
Job Responsibilities of Health claim investigator:
- To take the in charge of medical provider network management functions
- Empanelment of health care provider network
- Hospital & Diagnostic center empanelment’s ( Network – Tie ups),
- Tariff Negotiation and updation,
- Wellness activities of corporates,
- Grievance handling
- Hospital relationship
- To oversee and get actively involved in negotiating best tariffs for the medical services extended by the medical providers.
- To be responsible for the day to day operations and health care provider relations.
- Closely coordinate with claims department as a liasoning officer between internal team & networks by ensuring the claim services are issued as per agreed TAT.
- To analyse network performance to further optimize provider and network engagement opportunities
- Indian Insurance industry is now witnessing exceptional growth with private player taking maximum stakes in Indian Insurance companies creating ample job opportunities.
Developing country like India is a huge market for growing Insurance needs; this creates huge job opportunities for the aspirants. There are total 33 of General Insurance companies almost all offering health insurance policies to their customers out of which 6 are Standalone health insurance companies while there are 24 Life insurance companies operating in India. Considering above figure it’s obvious to suppose that India has big market for insurance business & health care professionals can grab this opportunity.