Interfaces to external or internal databases, extensive contractual relationships and multi-layered billing models – for health insurance funds, contract management is not possible without a well thought-out system. The standard functions of a contract management solution map basic processes. For health insurance funds, the software must be adapted and expanded. With their expertise and extensive experience from previous projects, otris consultants are ideally placed to support health insurance companies with enterprise-wide digital contract management.
Example of selective contracts
Health insurance companies are obliged to provide a legally defined scope of services. These services are anchored in collective contracts that health insurance funds conclude with the Association of Statutory Health Insurance Physicians, for example. Services that health insurance funds offer their members in addition to this are handled through selective contracts. The special feature: the health insurance fund concludes selective contracts directly with the service providers (e.g. specialists, hospitals, medical care centres) and not with the Association of Statutory Health Insurance Physicians. As a result, health insurance funds have to manage selective contracts that contain thousands of different contract participants per individual contract. This creates the challenge of assigning a large number of data records to a contract within the system and keeping these dynamic data records up-to-date. In addition, selective contracts contain one or more ICD assignment(s) to link a disease class (ICD = International Statistical Classification of Diseases and Related Health Problems). In summary: Compared to usual contracts with two contractual partners and without dynamic content, the effort involved in a selective contract is considerable.
Managing data with interfaces
Managing the entire stock of selective contracts of a health insurance fund is thus only possible via complex data management and interfaces to existing databases. For the database connection (e.g. to the Bitmarck ICD database), the otris experts rely on proven, self-developed interfaces. Via the connections, not only is the selected data linked to the contract, but it is also compared and checked for up-to-dateness. The system automatically synchronises changes in the contract participants (e.g. due to practice discontinuation or service changes). At the same time, it remains possible to change data records manually.
Complex contracts, complicated billing
The complex contracts inevitably require equally complex billing. otris contract also supports health insurance companies in this business-critical corporate process: in order to check the legality of submitted bills, the system exports the contract data in order to subsequently enable automated reconciliation. After the export, the data is available for a check that combines the speed of automation with the special case check of the clerks.
Simplify through digitalisation
The complex administrative structure of the selective contracts shows only a small section of the contract management of a health insurance fund. Rehab framework contracts with their variable scopes of benefits, drug discount contracts or contracts for GP-centred care (HzV) are other areas that require comprehensive data management. The overriding intention behind every process in the contract management of a health insurance company can be summarised simply: The insured person should receive the benefit to which he or she is entitled quickly and with little administrative effort. This only works if health insurance companies enter into direct contact with their policyholders and advise them according to their needs. Here too, otris software provides support with individual solutions.
On request: with geo-information system
The otris consultants develop interfaces to systems that health insurance fund employees use in customer consulting. A proven extension of the contract management software otris contract links contract data with geoinformation. In this way, the system delivers results in response to queries that health insurance employees need for targeted counselling sessions. For example: the address of the nearest doctor who provides a certain selective service. Or a list of all doctors within a radius of 50 kilometres who provide a certain selective service.
Health insurance funds aim to provide their members with individualised care and services tailored to their needs. At the same time, more individuality means more complexity in the contractual relationships that form the basis of service remuneration. otris software supports health insurance companies with customised, digital solutions that simplify complexity. By structuring, interfacing and automating contract management, health insurers save resources that are used to implement the primary task: To provide each member with sufficient, appropriate and economical care when needed.