Commercial insurance payment and medical insurance payment each have their own characteristics, and there are also places where they are interrelated. In this article, the author elaborates on the integration of medical insurance payment and commercial insurance payment, as well as the corresponding process of commercial insurance claims, etc., so you might as well take a look.
I discussed the content related to medical insurance funds, medical insurance payment and Internet hospitals, and today I will talk systematically about the integration of medical insurance payment and commercial insurance payment, especially the settlement or direct payment of commercial insurance in medical scenarios.
With the continuous improvement and development of the social welfare system, commercial insurance and social medical insurance have developed rapidly, showing their own characteristics in the development and interrelated.
In the process of carrying out practical work, it has been fully demonstrated that only by integrating commercial insurance and social medical insurance can the economic and social benefits be maximized, and this is also the main direction of the reform of the social security system in the mainland for a long time.
Social medical insurance often only covers part of the medical expenses, and may not be able to fully cover the high medical expenses. Commercial insurance can provide different levels of protection according to individual needs, including higher sum insured and more comprehensive coverage, to deal with possible major medical risks.
Commercial insurance plays an important role in supplementing public health insurance. Public health insurance, such as social health insurance, usually covers basic medical expenses, but may not fully meet the needs of an individual or family in the event of a significant medical risk.
Commercial insurance can effectively supplement the coverage of public medical insurance by providing broader and more personalized protection, so as to provide people with more comprehensive medical protection.
1. Relevant policies
Regarding the implementation and policies of commercial insurance in the medical field, the state also has relevant policies to support the implementation of commercial insurance in the medical field.
On December 27, 2016, the State Council issued Guo Fa [2016] No. 78 "13th Five-Year Plan for Deepening the Reform of the Medical and Health System", Article 5 of which promotes the development of commercial health insurance. Actively give full play to the advantages of commercial health insurance institutions in actuarial technology, professional services and risk management, encourage and support their participation in medical insurance handling services, and form a new pattern of diversified management and multi-party competition. On the premise of ensuring the safety and effective supervision of the fund, the government entrusts qualified commercial insurance institutions and other social forces to participate in the handling of basic medical insurance services in the form of government procurement services, and undertakes serious illness insurance for urban and rural residents. In accordance with the relevant provisions of government procurement, select commercial insurance institutions and other social forces to participate in the handling of medical insurance. Accelerate the development of medical liability insurance and medical accident insurance, and explore the development of various forms of medical practice insurance. Enrich health insurance products, vigorously develop consumer-oriented health insurance, promote the development of various types of health insurance, and strengthen the protection attributes of health insurance.
On June 10, 2019, Article 18 of the document "Opinions on Promoting the Sustainable and Healthy Development of Social Medical Institutions" [2019] No. 42 supports the development of commercial health insurance. Encourage commercial insurance institutions and social medical institutions to jointly develop diversified and personalized health insurance products, and form a complement to basic medical insurance. Encourage commercial insurance institutions to participate in basic medical insurance handling services, do a good job in undertaking serious illness insurance services for urban and rural residents, and improve the efficiency of fund use. Support the docking of the information system of commercial insurance institutions with the information system of social medical services, so as to facilitate the provision of one-stop direct payment and settlement services for commercial insurance patients. Encourage commercial insurance institutions to invest in social medical services.
On February 25, 2020, the Central Committee of the Communist Party of China and the State Council issued the "Opinions on Deepening the Reform of the Medical Security System", Article 8 promotes the development of a multi-level medical security system. Strengthen the triple protection functions of basic medical insurance, serious illness insurance and medical assistance, promote the complementary connection of various types of medical insurance, and improve the level of protection for major and extraordinarily serious diseases and diversified medical needs. Improve and standardize serious illness insurance for residents, subsidies for large medical expenses for employees, medical subsidies for civil servants, and supplementary medical insurance for enterprises. Accelerate the development of commercial health insurance, enrich the supply of health insurance products, make full use of the individual income tax policy of commercial health insurance, and study and expand the scope of insurance products. Strengthen the supervision of market behavior, highlight the supervision of key links such as the design, sales, and payment of health insurance products, and improve the capacity of health security services.
2. What is the difference between commercial insurance and medical insurance?
We ordinary people know that commercial insurance and medical insurance are different, so what are the specific differences? What are the differences? How are they reimbursed? Before formally introducing the content of commercial insurance, let's first briefly understand the general difference between commercial insurance and medical insurance.
1. Attributes and purpose: As a national social security system, medical insurance aims to protect and improve the health of employees. It is mandatory, and all types of employers and individuals must participate in accordance with the law. Commercial insurance, on the other hand, is opened by commercial insurance companies for the purpose of profit, which is not mandatory, and consumers can choose flexibly according to their own needs.
2. Degree and scope of protection: Medical insurance mainly provides basic living security for residents, and its insurance coverage is relatively wide, covering major and minor diseases, but the reimbursement ratio and degree of protection may be relatively limited. Commercial insurance, on the other hand, provides a more flexible and personalized protection plan, and its insurance payment is often proportional to the premium paid, and the protection content is relatively comprehensive, which can make up for the lack of medical insurance.
3. Role and object: The role of medical insurance is mainly to ensure the basic life of residents, and it is aimed at all citizens. Commercial insurance, on the other hand, is mainly to meet the needs of some people to obtain additional protection, and its protection objects are mainly natural persons.
4. Rights and obligations: In medical insurance, rights and obligations are not equal, because medical insurance is mandatory, beneficial and universal, and individuals only need to pay a small fee to enjoy the corresponding insurance benefits. In commercial insurance, the rights and obligations are based on the contractual relationship and are commercial in nature, and the rights and obligations between the insurer and the insured are reciprocal.
5. Payment and claims: Medical insurance payment is usually combined with the social security system, and part of the cost is paid directly by the medical insurance when the patient seeks medical treatment, and the remaining part is borne by the individual. Commercial insurance is more flexible in terms of payment options, which can be a lump sum payment, a pro-rata reimbursement or an allowance depending on the insurance product.
3. Commercial insurance claims reimbursement
Commercial insurance can provide a more personalized protection plan, and everyone's medical needs are different, some people may be more concerned about the protection of specific diseases, while some people may be more concerned about the protection of outpatient medical care.
Commercial insurance can provide customized protection solutions according to individual needs and preferences to meet the medical security needs of different groups of people.
Some commercial insurance products not only provide financial security, but also provide health consultation, health management and other services to help individuals better manage their health and prevent the occurrence of diseases.
It should be noted that commercial insurance is not a complete replacement for public health insurance. As part of the social security system, public medical insurance is mandatory and inclusive, and aims to protect the basic medical needs of the general public.
Commercial insurance is a voluntary insurance product, and the scope and extent of its coverage depend on the individual's choice and purchasing ability. Therefore, in the medical security system, public medical insurance and commercial insurance should complement each other and develop in a coordinated manner to jointly provide people with better medical security.
As shown in the figure: the process of commercial insurance payment (claims).
Commercial Medical Insurance Reimbursement Process:
1. In the event of an accident or illness that requires medical expenses, the insured person should report the accident to the insurance company immediately. The timeliness of reporting is critical to the subsequent claims process, and delays in reporting may affect the claims process.
2. During the treatment, all relevant medical documents and certificates should be properly kept, which will be an important basis for claims. The specific claim information requirements are subject to the requirements of the insurance company.
3. With the assistance of the insurance company, prepare the information required for reimbursement: if it is an outpatient clinic, it generally needs an outpatient medical record book, an outpatient invoice, etc.; if it is hospitalized, it generally needs a disease diagnosis certificate, a discharge summary, a medical insurance statement, a list of hospitalization expenses, an invoice for hospitalization expenses, etc.; if it is an accident, it is generally necessary to provide an accident certificate, etc.;
4. After the insured completes the diagnosis and treatment, the information is ready, apply to the insurance company for reimbursement, and submit the prepared claim information to the insurance company. After receiving the claim information, the insurance company will usually accept the claim within 3 working days, make a review within 5 days, and make an approval within 30 days if the situation is complicated.
5. The insurance company will review the submitted claim materials to determine whether they meet the agreed conditions and scope of the insurance contract. If the insurance company approves the review, it can be reimbursed.
6. After the review is passed, the insurance company will pay the claim within a few working days. As long as it is within the scope of the sum insured, it can theoretically be reimbursed multiple times until the maximum amount of insurance is reached.
Fourth, the integration of medical insurance/commercial insurance
Commercial insurance can be used as a supplement to social basic medical insurance, make up for the shortcomings of social insurance in terms of coverage and reimbursement ratio, and realize the integrated payment of medical insurance and commercial insurance, and the data between the two are smoothly connected and complementary.
Patients can pay part of the money through medical insurance, and then the rest will be paid by commercial insurance. The integration of medical insurance and commercial insurance in terms of payment further simplifies the payment process, thereby minimizing the financial burden of patients and improving the coverage and effectiveness of medical insurance.
As shown in the figure: integration of medical insurance & commercial insurance
Based on the medical insurance data, it realizes the risk analysis of underwriting and claims verification business for insurance companies, assists insurance companies in making decisions on two cores, and reduces the risk of adverse selection of commercial insurance insurance and claims.
According to the analysis of medical insurance settlement data, the compensation amount of commercial insurance products purchased by users is calculated, helping insurance companies to carry out rapid claim settlement services and solving difficult problems such as difficulty in reimbursement and multiple trips in traditional claims.
Open up the tripartite data of medical insurance, commercial insurance, and hospitals, analyze and calculate the claim amount of commercial insurance products at the same time as the settlement of medical insurance in the hospital, directly deduct medical expenses, reduce the burden of large medical expenses, and greatly improve the efficiency and service experience of commercial insurance claims.
5. Commercial insurance direct compensation/quick compensation
The application of commercial insurance in medical scenarios covers a variety of models, including commercial insurance direct payment, commercial insurance rapid claim settlement, commercial insurance customized insurance, health management services, mutual insurance, etc.
Today, I will mainly introduce to you two common models: commercial insurance direct payment (direct compensation) and commercial insurance quick compensation.
So what is a commercial insurance quick claim?
Commercial insurance quick claim refers to the rapid claim settlement service of commercial insurance. This service is designed to improve the efficiency of claims settlement, simplify the claims process, and enable the insured to receive claims faster.
Commercial insurance quick claims are usually made through online platforms or mobile apps, and the insured only needs to download and register the corresponding quick claim app, and then upload the relevant supporting documents and materials to submit a claim application. These claims are reviewed and evaluated by the insurance company and the claim is paid promptly after confirmation that the claim is correct.
Commercial insurance quick claims provide a faster and more convenient way for the insured to settle claims, so that they can get timely financial protection in the face of unexpected risks.
Compared with the traditional way of claiming, the quick claim of commercial insurance is more convenient and efficient, which greatly shortens the claim cycle and reduces the financial pressure of the insured.
In addition, commercial insurance quick claims also use advanced technologies such as big data and artificial intelligence to conduct rapid review, which improves the accuracy and efficiency of claims.
As shown in the figure: commercial insurance quick compensation
The process of commercial insurance quick claim settlement is to directly obtain the medical settlement data from the medical insurance for analysis, calculate the insurance liability amount and output it to the insurance company, and quickly pay the claim after the insurance company reviews and finds it correct.
While greatly improving the speed of claim settlement, users can also view the progress and details of claims through the mobile terminal, enhance the transparency of claims settlement, and improve users' medical payment ability.
So what is commercial insurance direct indemnity?
Commercial insurance direct compensation is a form of claim settlement in commercial insurance, which usually refers to the settlement of compensation payments directly between the insurance company and the insured or related service providers (such as hospitals, garages, etc.), without the need for the insured to pay the fee in advance and then apply for a claim.
When the customer is discharged from the hospital, the claim payment can be directly deducted from the medical expenses, and the customer does not need to go back and forth to collect and sort out the relevant materials of the claim many times, which truly realizes the convenient and efficient instant "second compensation".
The core of this method lies in "direct claim", that is, direct compensation, which simplifies the traditional claim process and reduces the economic pressure and operating costs of the insured.
Commercial insurance direct claims usually involve direct cooperation between the insurance company and the medical institution. When a customer receives treatment at a partner medical institution and incurs medical expenses, the insurance company will settle directly with the medical institution and pay the amount payable directly to the medical institution, so that the customer only needs to pay the remaining part of the expenses when discharged from the hospital, and there is no need to wait for the insurance company's claim.
The advantage of commercial insurance direct claim is that it greatly simplifies the claim process and reduces the waiting time and inconvenience for customers. At the same time, through digital operations and close cooperation with medical institutions, insurance companies are able to process claims more quickly and accurately, improve the whole process of services including underwriting, preservation, renewal, claims settlement and value-added services, and customer satisfaction.
As shown in the figure: commercial insurance direct compensation
The user's medical treatment settlement information will be analyzed and calculated on the platform in real time, and the calculation results of the commercial insurance claim amount will be returned to the medical insurance settlement system, and the medical insurance system will transmit the results to the hospital side. (Taking Huimin Insurance as an example, only a few cities such as Shenzhen, Guangzhou, and Hangzhou have achieved direct compensation for more than 100 Huimin Insurance projects across the country)
6. Introduction to the business process of commercial insurance claims
At present, the traditional manual claim settlement method is widely used in commercial medical insurance across the country, and there are problems such as complicated procedures, long cycle and low efficiency, especially the provisions of "settlement of claims for the insured according to the settlement of social medical insurance" set in the terms of commercial insurance, which has become an obstacle and bottleneck restricting the efficiency of commercial medical insurance settlement.
Insurance companies and social medical insurance systems to achieve effective docking and other data connectivity issues, break down data barriers, open medical insurance settlement data to commercial insurance companies authorized to open, under the condition of individual authorization and consent to ensure data security, to achieve commercial medical insurance and social medical insurance data interoperability, sharing and integrated application.
Commercial insurance users can settle with social medical insurance in real time when they are discharged from the hospital, and can make online claims without submitting paper materials.
As shown in the figure: the business process of commercial insurance claims
Commercial insurance claims are divided into three main parts: direct claim, application/surrender and post-claim, from which we break down the entire process from insurance application to claim in detail.
1. In the direct compensation part, two scenarios are shown: offline scenarios and online scenarios. In the offline scenario, users can make direct compensation through the charging window. If the user chooses to seek medical treatment in the hospital, they can interact with the hospital's HIS system for the settlement of medical insurance or commercial insurance.
The settlement service and mobile settlement service of the medical insurance center calculate the amount of medical insurance payment and the amount of commercial insurance claims for medical insurance and commercial insurance, and the medical insurance settlement center distinguishes the amount of medical insurance payment and the amount of commercial insurance payment when the user pays medical expenses according to the calculation results.
2. In the part of application/surrender, online and offline scenarios are distinguished. In offline scenarios, users may need to interact with the medical insurance center to complete the relevant application or surrender process. In the online scenario, users can settle commercial insurance online (WeChat official account, APP, etc.) to achieve convenient insurance application or surrender operations.
At the same time, the policy change notification is also an important part of this section to ensure that users can keep abreast of changes in policy status.
3. The post-claim part mainly involves the calculation of the claim, the acquisition of result data and the payment of funds. Claims pre-service and claims calculation engine are key components to ensure the accuracy of claims calculations.
In addition, through the interaction with the big data computing platform, more abundant indicator data can be obtained, which provides strong support for subsequent claims management.
Finally, the insurance system is responsible for completing the payment of funds to ensure that users can get the amount of compensation they deserve in a timely manner.
In the process of integration of medical insurance and commercial insurance, different application ends, Internet areas and medical insurance private network areas are also involved, which are all to achieve smooth processes and secure data transmission. At the same time, the interaction with the IDC of the National Health Insurance Bureau is also an important part of ensuring that the entire claims process complies with relevant policies and regulations.
The whole business process comprehensively demonstrates the whole process of commercial insurance claims, from insurance application, claims settlement to data analysis, providing users with a high-quality claims service experience and providing strong technical support for insurance companies.