Introduction:
Medical insurance is one of the most important financial sources that covers the cost of medical treatment in the private health sector. 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 to be fully aware of all terms.
Also, individual and group insurance contracts include disclosure in the insurance application, referring to the statements in the application; either the company accepts the insurance, rejects it, or covers it on limits. After the contract is issued, the insured benefits from the network of service providers contracting with his insurance company.
The insured goes to the service provider (Hospitals, Clinics, Doctors, Pharmacies, etc.) and requests approval for the treatment. In this service, the beneficiary obtains approval or rejection of the service based on the terms of the contract.
Throughout this course, we will delve into the intricacies of medical insurance management, focusing on the role of the medical insurance manager and the critical importance of global medical management insurance.
By participating in our comprehensive medical insurance training and following the robust medical insurance course syllabus, individuals will gain the expertise needed for executing effective medical management programs in insurance.
Target groups:
- All managers are responsible for the insurance sector.
- All managers in charge of social insurance.
- Employees of the health insurance department in insurance companies.
- Staff working in the health insurance department of service providers.
- Health insurance department employees across various institutions.
- Individuals seeking to enhance their skills and experience in medical insurance management.
Course Objectives:
At the end of this medical insurance management course, participants will be able to:
- Differentiate between individual and group contracts.
- Recognize various group insurance types.
- Acquire knowledge of different health insurance.
- Understand medical providers and their networks.
- Grasp the concepts of underwriting and claims management.
- Become proficient in managing health insurance files.
- Develop skills for negotiating health insurance contract renewals.
- Learn efficient health insurance correspondence.
- Comprehend health insurance contracts and diverse coverages.
- Master medical expense management and premium management.
Targeted Competencies:
Upon the end of this medical insurance management Training, participants competencies will:
- Understand Medical Insurance Policies and Regulations.
- Claims Processing and Adjudication.
- Risk Management in Health Insurance.
- Customer Service and Communication Skills.
- Data Analysis and Reporting.
- Fraud Detection and Prevention.
- Medical Billing and Coding.
- Compliance and Ethical Standards.
- Financial Management and Budgeting.
- Health Informatics and Technology Use.
- Strategic Planning and Policy Development.
- Provider Relations and Contracting.
- Quality Assurance and Improvement.
Course Contents:
- The inception of insurance and risk management.
- Detailed exploration of medical insurance.
- Medical insurance contract management.
- Technical study of medical insurance.
- Financial details of medical insurance.
- Significance of personal accident documents in medical insurance contracts.
- Strategies to detect medical insurance fraud.
Unit 1: Health Insurance The Origin, Objectives, Principles:
- Insurance providers and their roles.
- The origins of insurance and the practice of risk management.
- Objectives and primary benefits of health insurance.
- Key terms and foundational principles in insurance.
Unit 2: Medical Insurance:
- Various types of insurance.
- Legislation governing health insurance.
- Health insurance policy categories.
- Coverage under permanent health insurance.
- Framework for structuring health insurance programs.
- Overview of deductibles and cost-sharing measures.
Unit 3: Medical Insurance Contract Management:
- Efficient health insurance correspondence.
- Roles of the underwriter and claims adjuster.
- Medical expense and premium management, including financing.
- Self-financed health insurance funds and their operation.
- Claim calculation methods.
- Factors influencing health insurance premiums and insurer decisions.
- Relationships with medical service providers.
Unit 4: Technical Study of Medical Insurance:
- Introduction to healthcare delivery systems.
- The extent of coverage considerations in health insurance.
- Strategies for negotiating health insurance contract renewals.
Unit 5: Financial Study of Medical Insurance:
- The concept of the actuarial study in health insurance.
- Applications of actuarial studies in the field.
- Essential skills for health service providers.
- The role of reinsurance in pricing health insurance.
Unit 6: Personal Accident Document and its Importance for the Medical Insurance Contract:
- The definition of personal accident documents.
- Policy coverage under personal accident insurance.
- The interconnectedness of personal accident documents and medical insurance.
Unit 7: Detecting Medical Insurance Fraud:
- The significant impact of fraud on insurance contracts.
- Tactics for identifying medical insurance fraud.
- A variety of fraud detection methodologies.
