Healthcare Program Design and Modification

Health plan developers face many challenges in providing stable, sustainable health care benefits. They need to manage the costs of their health care plans within the organization’s financial framework and structure in order to be more efficient, while continuing to offer a slate of health care benefits that allows the organization to be competitive in the marketplace. Over the years, GlobeMed has overcome these challenges to design, rate and implement several strategic and successful programs to be sold our franchisees. These programs include managed care plans with hospital benefits, ambulatory services benefits, primary care programs, prescription medicine benefits, dental programs, travel insurance, expatriates and expatriation services, telemedicine services for second opinion consultations, international health services, and managed primary care (health and dental).

Benefits Administration, Members’Enrolment and Underwriting Services

We pride ourselves on not leaving anything to chance. We carefully study and revise our services to allow our clients to get the most out of them. That’s why we provide them with the necessary infrastructure to efficiently manage the administration of their benefits. This includes the following functions:

•Definition of benefits and restrictions, underwriting rules (program eligibility rules) and premium structure (employee contribution, etc.)

•Technical and medical underwriting automation

•Production, card issuing, policy management and policy owner services

•Reporting and interface with a third party administrator and a preferred network of providers

Management of Preferred Providers Networks

We provide our franchisees with a complete set of tools to manage their networks of local and international healthcare providers. Our solution comes with an elaborate database of providers that is integrated with other modules; including benefits and member’s administration, claims management, and customer services, in addition to a web-enabled portal that enables users to easily and efficiently communicate with the insurer/TPA. Contracts with various healthcare providers are executed on the basis of direct billing, preferred tariffs and discounts, and involve administrative and medical protocols with which providers need to comply.

Claims Management

1-    Admissions and Medical Review

We know how frustrating it is for clients to not get the care they want when they so desperately need it. A company’s availability and readiness to provide immediate customer support do not only reflect on its image, but also on its customer satisfaction levels. That’s why we’ve developed a solution that allows our franchisees to manage a 24/7 customer support center(s) ensuring pre-certification of admissions on the basis of policydefined benefits, medical necessity, and customary practices. Claims and patients’records are reviewed in real time to reconcile declared admission parameters, actions implemented and billed services. These processes are powered by an advanced online system that verifies the medical and contractual eligibility of each transaction being processed.

2-    Eligibility Control, Claims Processing and Claims Settlement

Uninterrupted connectedness is at the heart of our services. We provide healthcare providers, who join GlobeMed’s franchisees network, with a web-based portal that allows them to verify the eligibility of the patient and immediately process his/her claims by themselves on the system anytime. The software itself runs the necessary checks to make sure that the claims entered are adjusted according to the coverage terms and agreements with the provider involved. Differences in conditions of benefits are addressed as easily as basic programs. The claims settlement process is fully automated thanks to the integration of an accounting system and preset notifications that are sent to providers and insurers.

In addition, the system includes features that promote cost savings, quality care and efficient workflow management.

Management of Customer Services through Call Centers

We are committed to providing full solutions down to the smallest detail. Our comprehensive approach to work allowed us to expand our Call Center concept to provide an array of services over the phone, including pre-admission services, administrative information, IT helpdesk, complaints handling desk and healthcare information. The latter service is a unique benefit offered to the insured, enabling them to call a physician or a nurse 24/7 and inquire about any health-related issue. Respondents will never diagnose a condition or prescribe medication, but will follow accredited pre-set protocols and algorithms, allowing them to attend to the caller’s concerns.

Support for Reinsurance Companies

Reinsurance helps insurance companies protect themselves against large claims, increase their capacity to insure large risks and avoid

fluctuations in their results. Through its partner reinsurance companies, GlobeMed provides insurers with tailored services to keep their businesses afloat. These include treaty administration, early warning system development, risk evaluations and rate adjustments, actuarial studies, and reinsurance accounting.