Client is a service-based organisation with offices in Hyderabad, New Delhi, Mumbai and branches across the country. It is in the business of providing third party administration services to Insurance companies into the domain of Health Insurance. ZAAX Consulting PL (ZCPL) would like to develop a comprehensive online software solution to automate its entire operations from collection of policies to underwriting, issuance of cards, claims processing, Accounts, CRM and performance monitoring. The objective of this software is to increase the efficiency of operations and to drastically cut down the response time to the policyholders as well as to the insurance companies and network hospital as these are the three basic and major entities in whole system.
The system is proposed to be built on Java Platform. This platform gives us the flexibility of speed, scalability, security, performance and allows for independence of hardware, CPU, platforms. Unlike .NET/Windows, JAVA platform does not have per user license issues and is not limited to specific operating systems. The system shall be developed using industry standard MVC architecture using a templating engine, a model, view and controller for each module and sub-module.
Oracle 11g is proposed as the database server.
Glassfish or JBoss proposed as the application server.
Intel or AMD 64bit hardware architecture is proposed.
The process starts with a contract entered with an Insurance company to provide third party administration services to its policyholders in a designated area. The contract can be with a new company for a designated area of operations or with an existing client for a new area. The Head office (HO) is the national headquarters of the insurance company. These insurance companies divide their geographical area of operations into regions, which are served by the Regional office (RO). Each regional office has a number of divisional offices (DO) under it. The divisional offices have a number of Branch offices (BO) or Direct agent branches (DAB) under it. Once the contract is signed with an insurance company the data related to the offices of the company within the specified territory assigned to ICare will be captured and maintained by the System Administrator. This will include:
Once a contract is signed, the collection team of ICare starts moving to the respective issuing offices of the insurance company in the region to collect new policies. This module covers the following activities:
This module basically involves capturing the entire data available for each insurance policy and each life that is insured by the underwriters. It serves as the master database from which the claims team derives all the information required for processing of claims. The main activities involved in this process are: All the policies are classified appropriately and their data is captured. The policies can be Individual policies or group policies. Individual policy parameters are standard for all the GICs while in the case of group, the policies are tailor-made though usually within predefined parameters. Now lot of policies are coming with different specification so we have to develop according to need. Individual policies may be either new policies, renewal policies or transfer policy and with individual sum insured, family floater sum insured. However group policies having Disease floater, Corporate floater and includes all the types sum insured of individual policies.
The form for feeding data for an individual policy will be a standard form which will capture data relating to issuing office, insured person, dependants, Policy type whether there is any endorsement or not, details of sum insured, net premium, details of pre existing diseases etc.
Cards and record section is involved in keeping the physical files of all the policies hat arrive and also involved in issuing cards and dispatching them to the insured. This module will cover the following activities:
The claims team is involved in authorising a claim that comes from any of the policyholders and to settle the claim. Authorisation is required in case the patient wants to avail of the cashless benefit in any of the network hospitals. In case the patient has sought treatment in a non-network hospital, the claim is raised after the patient is discharged from the hospital. However the patient may choose to intimate ICare regarding the forthcoming claim. Third option for the policyholder is to avail of the services from any hospital at his own expenses and then raise the claim for reimbursement without Intimating ICare in advance. Claims will be automatically soft adjudicated when ever possible.The following activities are covered in the claims modules:
Reauthorisation request will be treated as a part of the same authorisation and will be issued a sub claim control number if applied for within a fixed span of time. The same process will be followed for reauthorisation claims as for authorisation claims.
Claims processing starts with the receipt of a physical claim with the bills from an insured or the hospital. This could be a claim, which has been raised directly or one, which was intimated earlier. A hospital will send claims related to the authorisations it had received.
Once the claim processing is completed, the claim comes for audit purpose. The role of auditor is to cross verify all the important transactions happened in that claim. It starts from name, sum insured, balance limit, policy terms to disease and conditions and physical verification of claim file. Once auditor is satisfied then it moves to account for cheque printing. However auditor can send back the file to doctors with his remarks.
The Accounts module covers the following activities.
The CRM module will support the following functionalities.
The system will allow for the creation of a number of reports, which are for the Insurance companies, the IRDA, the hospitals, the corporate clients and for the Management.
In this module we will cover basically the claims part which includes queuing of jobs, allocation of jobs, escalation of jobs if not attended in a particular time limit and monitoring of job. This process involves scratch from registration of claims to despatch of cheques. Some of the functionalities of this module are
The application will be designed & developed to provide IVRS interface to allow accepting queries over phone (by dialling no.), verify the input received and extract relevant message to be played over phone as response. The numbers will come from the system database. These numbers will be converted into the audio for playing over the telephone line. To achieve this, audio recording would be carried out and stored in the database and the application server will be integrated with an Interactive Voice Recognition (IVR) card. Further we can design a report where certain statistics can be prepared However this will need further discussion to finalise the requirement.
This module will assist in defining the different access levels for the employees and Management. The administrator can use the module to carry out the following functionality.
Apart from CRM functionality this module will cover certain categories of caller, register their grievances and give a time to sort out the issues. The main caller categories includes
This is a total internal process. A higher authority can issue a ticket to his subordinates for any specific issues. This ticket can be closed by the originator only. A certain time limit will be decided so that any issue will have to sort out by the specific time only.
User DBThere will be masters for Insurance company, Insured persons, hospitals, policies, Brokers, Agents, Corporate, Disease code, Procedure Code etc. All the functionalities will be done by the permission given to users to create or modify records.
This module will cover designing the inventory management system. It will manage vendors, Process reorder level , masters for vendors, their rating etc.
CRM is the most expensive now a days. So in order to cut down cost and enhance performance web site is the most economical model. Website will be online and policy holder can see his / her policy details, claim details etc. Network hospital can keep a watch on his claims without bothering TPA for reconciliation and status of payment. Insurance company can take some MIS according to his needs. Apart from above we can share some information like network hospital list, our branches, contact info, general guidelines etc.
We will provide hospital to upload the scan copy to the website for faster processing. However the physical copy can be sent to the branches every week. So the processing will be faster and there will be no movement of physical file.
In this module, a network hospital can be added, de panelled, deleted. The networking guy will be responsible for negotiating packaged rates and tariffs and he will enter all the details to the system. The system will generate the no of claims paid, outstanding etc so that he can follow up with the hospital.
This module will facilitate the corporate relation manager from policy entry to claims information also maintain the claim ratio. This module will give alert before 1 month, 15 days, weeks and 3 days before expiry. It also produce a list of corporate to be renewed in next month.
This module will eliminate the physical correspondence communications. What ever the letter, query reply, cheque, grievance etc will be documented and forwarded to the designated person. This module will be acting like inward and outward register.
Performance is the heart of the organisation. This module will monitor the performance of all employees. All the process will have certain time limit to finish. If there is any alteration in that then system will show the exception. For example if a claim should be processed in 3 days then it will shows all the claims which does not meet this timeline. Also it will fire a email to the supervisor to investigate the problem. This module also records the efficiency like how many has been punched by which data entry operator by how much time etc.
Every user in the system will get a dashboard where everybody task is predefined by the superior or by system. User has to click and start working on that. In this was the task can be pushed and user will get a feeling of getting the work done.