Medical Insurance Management

Introduction:

Medical insurance is one of the most important financial sources that cover the cost of medical treatment in the private health sectors, it’s a contract between the health insurance holder and the insurance company, medical insurance has conditions and the purchaser of the insurance contract must read it carefully in order to be fully aware of all terms.
Also, individual and Groups insurance contracts have disclosure included in the insurance application, referring to the statements in the application, either the company accepts the insurance, rejects it, or covers on limits, After the contract is issued, the insured benefits from the network of service providers contracting with his insurance company, where the insured goes to the service provider (Hospital – Clinics – Doctors – Pharmacies. etc.) and they request approval for the treatment. In this service, the beneficiary obtains approval or rejection of the service based on the terms of the contract.

Target groups:

• All managers responsible for the insurance sector.
• All managers responsible for social insurance.
•  All employees of the health insurance department in insurance companies.
• All employees of the health insurance department of service providers.
• Employees working in the health insurance department in all institutions.
• Anyone who finds himself in need of this course and wants to develop his skills and experience.

Course Objectives

At the end of this Course, participants will be able to:

• Recognize between individual and group contracts
• Recognize between the different types of groups insurance 
• Know the types of health insurance.
• Knowledge of medical providers and the medical network.
• Understanding of underwriting and claims management.
• Health insurance file management.
• Negotiating the renewal of health insurance contracts.
• Health Insurance Correspondence.
• Understand health insurance contracts and different coverages.
• Medical expense management and premium management.

Course contents

• The genesis of insurance and risk management.
• Medical Insurance.
• Medical insurance contract management.
• Technical study of medical insurance.
• Medical insurance financial study
• The personal accident document and its importance to the medical insurance contract.
• Detecting medical insurance fraud

Unit 1: Health Insurance "The Origin, Objectives, Principles"

• Insurance Providers
• The origins of insurance and risk management
• Objectives and benefits
• Insurance terms and insurance principles

Unit 2: Medical Insurance:

• Types of insurance
• Health insurance law
• Types of health insurance policies
• Permanent health insurance cover
• Preparing health insurance programs
• Deductible amounts and deductible ratios

Unit 3: Medical Insurance Contract Management:

• Health Insurance Correspondence
• Underwriter and Claims
• Medical expense management, premium management and financing
• Self-financing health insurance funds
• Claims and their calculation methods
• The method of calculating the health insurance premium and the most important factors affecting the decision of the insured (insurance company)
• Medical service providers

Unit 4: Technical Study of Medical Insurance:

• Introduction to the health care delivery system
• Extent of coverage in health insurance
• Negotiating the renewal of health insurance contracts

Unit 5:Financial Study of Medical Insurance

• Definition of actuarial study
• Fields of Actuarial Study
• Skills Needed by Health Service providers
• Reinsurance and its effect in pricing

Unit 6: Personal Accident Document and its Importance for the Medical Insurance Contract:

• Definition of a personal accident document
• Personal Accident Policy Covers
• Relationship of the personal accident document to the medical 

Unit 7: Detecting Medical Insurance Fraud:

• Impact of fraud on the insurance contract
• Detecting medical insurance fraud
• Fraud detection methods