For two decades, computerized audit systems have been an integral part of how almost all private health insurers in Germany regulate benefits. The use of these solutions has enabled insurers to significantly increase the degree of automation in their benefits processing, while also maintaining their host applications.
Yet it is precisely in this regard where a lot has changed in recent years: Most insurers are currently undergoing a process of transformation in order to replace their legacy systems - if they haven't completed it already. On the one hand, increasing the use of state-of-the-art standard software enables companies to ensure the future viability of their own IT infrastructure. On the other hand, state-of-the art benefits accounting and portfolio management systems enable their customers' concerns to be processed in a way that is digital, speedy, and transparent.
In the area of benefits regulation, however, it is becoming apparent that computerized audit systems optimized for host applications do not fully meet the requirements of state-of-the-art benefits systems.
What is the difference between the "old" and "new" world?
One difference between legacy systems and in|sure Health Claims that stands out is the level of detail with which an insurer's range of tariffs can be displayed by the technology. When using legacy systems, insurers are usually limited to determining deductibles based on the medical benefits that have been utilized. However, each time new tariffs are generated, not only do the deductibles change, the contents of the tariff benefits do as well. Yet these are barely reflected in the old models.
For this reason, the computerized audit systems have continuously been upgraded to include options for verifying tariffs. In the short term, this helped to mitigate the negative effects of insufficient tariff modeling capabilities and a lack of flexibility in the legacy systems. More long term, however, this approach has also caused some problems. On the one hand, tariff models have to be created and maintained twice. On the other hand, the modeling capabilities are far less powerful compared to in|sure Health Claims, and do not fully address the complex range of rates.
Adesso insurance solutions thus decided to develop a computerized audit system that is optimized for state-of-the-art benefits systems.
Other tasks for computerized audit systems
Our approach is that if the decision to reimburse is in any way dependent on an insured tariff, it is only made in the benefits system. Though computerized audit systems will still be needed in the future, they will have different tasks.
We will illustrate what this means in concrete terms using the example of vaccination against human papillomavirus (HPV)/cervical cancer. This is currently (September 2022) recommended by the Standing Commission on Vaccination (STIKO) for all girls and boys ages 9 to 17. Many private insurer tariffs thus reimburse the full cost of an HPV vaccine administered to anyone who falls within this age range. Up to this point, traditional computerized audit systems work well.
Once full legal age is reached, however, tariffs differ significantly in their reimbursement practices depending on the tariffs that are generated:
- The costs are not covered due to the fact that the vaccine hasn't been recommended.
- The costs are covered but are detrimental with regard to the possibility of premium reimbursement.
- The costs for preventive vaccinations that lack a special recommendation are covered, but they are capped at a certain amount per year.
Because only the benefits system knows which benefits are (not) detrimental or which amounts have already been paid out within a specific period, these verifications can also only be displayed correctly here. In order to automatically arrive at a decision, in|sure Health Claims only requires two additional features concerning the deducted benefit.
- For the vaccination in question, STIKO either recommends or does not recommend it for the person being treated.
- The vaccination in question is an HPV vaccination.
These features are in themselves completely tariff-independent - and thus ideally suited, along with fee-based medical and dental invoice verification, to become a significant component of our future computerized audit solution.
Would you like to learn more about state-of-the-art portfolio management and benefits management in private health insurance? Then please contact Karsten Schmitt, Head of Business Development.
