iMed

PBT’s Automated Invoice Adjudication Platform that enables health

insurers to achieve over 96% Straight Through Processing with an

85% reduction in manual invoice processing effort.

Australian Prudential
Regulation Authority

The Australian Private Health Industry is facing challenging times. The Australian Prudential Regulation Authority (APRA) recognises 36 private health insurers although almost 80% of members are covered by just 5 of them (BUPA, Medibank, HCF, NIB and HBF).

APRA has warned that only 3 of the 36 insurers will have a sustainable business model by 2022 raising the strong possibility of takeovers and mergers.

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Differentiate between insurers

The Federal government’s increased regulatory oversight and standardisation of private health insurance has made it harder for insurers to differentiate through product offerings and while debatably beneficial for consumers this change has undoubtedly increased the challenge for smaller health insurers in a crowded market.

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Improve efficiency and reduce costs

Health insurers by nature are only in control of a small percentage of their overall costs, with the overwhelming majority (over 85% on average) being paid as benefits to members. This leaves comparatively few levers to adjust in order to improve efficiency and reduce costs without adversely affecting the service to members. Many insurers are still working with inefficient legacy and paper-based systems, with an over reliance on manual effort for customer interactions and claims adjudication.

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Increased expectations from younger generations

Changing demographics exacerbate the challenges described above. An ageing population puts greater strain on insurance resources and younger, traditionally higher value, members are increasingly removing themselves from the private health insurance ecosystem. Some analysts suggest that up to 60% of Australians will drop private health by 2030.

Younger generations have increasing expectations about how they engage with corporate entities and expectations of the types of benefits that should be provided by their health insurance.

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Effective use of technology

The challenge to private health insurers is to reduce costs, without reducing correct payment of claims and simultaneously improve engagement with members. While challenging, this can be achieved with increased Effectiveness, Efficiency and Experience. Effective use of technology, Efficient use of resources and focus on customer Experience.

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Effectiveness

Increase claims handling accuracy – Reduce over and under payments.

Efficiency

Reduce claims expenses.

Customer Experience

Increase customer satisfaction

Automated Invoice Adjudication Platform

PBT’s Automated Invoice Adjudication Platform (iMed) allows health insurers to achieve over 96% Straight Through Processing with an 85% reduction in manual invoice processing effort. This ensures that claims are paid fairly and accurately first time, it avoids over payment and the necessary recovery, and it frees up valuable human resources to focus on member care and claim prevention. iMed users achieve a 20% improvement over industry average for management expense per policy according to APRA figures, allowing higher than industry average payment of benefits while still maintaining a greater net profit facilitating further investment into business, technology, and members.

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iMed Enables

  • Over 96% Straight Through Processing of Claims/Invoices
  • 85% reduction in manual effort processing claims/invoices in terms of FTE count
  • Over 16 million claims/invoices processed annually
  • Significant reduction in improper payments and increased fraud detection
  • Processing costs as low as 5c per invoice
PBT Quote

It’s all about claims. A policy can look great on paper, but the moment of truth comes when a customer lodges a claim and is expecting to be paid.

– Damien Mu, AIA Chief Executive Officer

Key Technology
Services

Policy Management

This capability provides the ability to obtain policies created and maintained in an external policy system.  

This capability also provides the ability to manage the policy’s Product Coverages including Waiting Periods, equity (tenure) and bonus entitlements.

Product Management

This capability provides the ability to manage products as reference data required for the assessment and benefit determination of claims/invoices. 

Provider Management

This capability provides the ability to manage providers as reference data required for the assessment of claims/invoices.

Schedule Management

This capability provides the ability to manage industry schedules as reference data required for the assessment and benefit determination of claims/invoices.

Claim / Invoice Management

This capability provides the ability to perform:  

  • claims/invoice submission,
  • re-submission,
  • adjudication (assessment),
  • benefit calculation including associated claim/invoice workflows and exception management.

This capability also provides the ability to manage enquiries related to previously submitted claims/invoices.

This capability fully integrates with all Mobile application platforms that will enable Members to submit Claims/Invoices from anywhere and enable them to manage their cover/benefits from anywhere.

Eligibility Management

This capability provides the ability to perform member (or patient) eligibility checks to confirm if the member is known at the Health Fund or if the member is covered for the requested service(s). 

It also provides the ability to manage enquiries related to eligibility checks completed previously.

Benefit Quote Management

This capability provides the ability to manage benefit quotations to confirm any out-of-pocket expenses as well as to manage enquiries related to benefit quotes obtained previously. 

The capability provides the member the ability to perform benefit quotation through any Mobile Application platform.

Contract and Agreement Management

This capability provides the ability to manage provider contracts and agreements as reference data required for the assessment and benefit determination of claims/invoices. 

Integration Capabilities

iMed provides the ability to integrate with external capabilities in support of an end-to-end claims/invoice processing solution:

  • Customer Relationship Management (CRM) – Claims/invoice enquiry services for consumption by CRM platforms.
  • Financial Management (Collections and Disbursements)Claims/invoice benefit payment notification services for publication to Finance Platforms. 
  • Reports ManagementClaims/invoice information publication services for publication to Reporting platforms. 
  • Correspondence (Fulfilment) ManagementClaims/invoice information publication services for publication to Correspondence (Fulfilment) platforms. 
  • Case/Condition ManagementClaim/invoice pre-approvals, disease management and ex-gratia payment services. 
  • Document ManagementConsumption of document search and retrieval services provided by Content Management platforms.
  • Analytics Management – Claims/invoice information publication services for publication to Warehouse or Analytics platforms.

FOCUS ON NEW DEVELOPMENT AND NEW BUSINESS OPPORTUNITIES

Having your core business running efficiently, effectively, and with a focus on customer experience allows the business and IT functions to focus on new development and new business opportunities rather than fire fighting and maintenance.

iMed’s architecture offers standardised and flexible integrations with back-end, external, and customer facing platforms to allow your business to focus on adopting new technology and enabling new channels of engagement. These new digital channels are the key to capturing a younger more tech savvy audience and driving younger audiences towards private health insurance.

iMed is a core technology platform that allows simple, API driven interfaces to enable development of exclusive digital channels and the seamless integration of wearable devices to drive further benefits to members and encourage the prevention first approach to health insurance. iMed is a core platform designed to integrate with and augment existing technology. Enabling accurate, real-time, automated invoice adjudication opens up new highly flexible and digitally innovative ways to operating and engaging with members.

iMed operates through open APIs allowing any platform or channel to securely access real times claims, and a 360º historic view of the customer. iMed enables your legacy solutions to operate in the new world opening up digital claiming through mobile, web, voice and IOT, the limits become your imagination, not your technology.

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