Claims Process Research Articles

The Insights of Experienced Pharmacists Regarding the Iraqi health Insurance Program: A Qualitative Study(Conference Paper )#

The aim of study was to explore pharmacist insights toward the impact of prospective implementation of the national health insurance program on patients, providers and Iraqi health system.
 This was a qualitative study including semi-structured face-to-face (mostly) interviews with experienced pharmacists. The interview guide included open-ended questions about the impact of the national health insurance program on patients and healthcare providers at three levels: quality of services, costs, and frequency of visits. Potential challenges were also discussed. Interviews were conducted in four provinces from March to May 2022. Thematic analysis was used to analyze the interview findings and generate themes and subthemes.
 The study recruited 21 pharmacists till the saturation point has been reached. Most of the participants were aware of the new health insurance law. Most participants believed that the program can enhance patient health and would increase the income of healthcare providers (HCPs) in the private sector. They also expected that patients would use private-sector services more frequently. Additionally, the implementation of the health insurance can improve the quality of healthcare services and reduce the financial burden regarding private sector fees. The potential challenges of the program include people's resistance to paying a monthly premium, difficulties in claims processing, potential delays in the reimbursement of HCPs, potential patient misuse of the insurance program, and the absence of an electronic system and database. There are not an adequate number of priced and tested medications.
 The health insurance program has several potential advantages, but at the same time it can face several technical challenges. The program should be well studied before implementing and it needs to be piloted at small scale before national implementation. The electronic system must be implemented by healthcare settings to facilitate transferring of the information/bills to the health authority. It is recommended to hire international team of experts to supervise the management this new system.

Optimal investment and reinsurance strategies for an insurer with stochastic economic factor

This work considers optimal investment and reinsurance strategies for an insurer with stochastic economic factor. In our mathematical model, a risk-free asset and a risky asset are assumed to rely on a stochastic economic factor which is described by a diffusion process. We generalize the claim process to a compound Poisson process with the stochastic economic factor. Using expected utility maximization, we characterize the optimal strategy of investment-reinsurance under the power utility function. We use dynamic programming principle to derive the Hamilton–Jacobi–Bellman (HJB) equation. Then, by analysing the solution of the HJB equation, the optimal investment-reinsurance strategy is obtained and given in the verification theorem. Finally, sensitivity analysis is given to show the economic behavior of the optimal investment and reinsurance strategies.

Deprescribing the Kt/V Target for Peritoneal Dialysis in the United States: The Path Toward Adopting International Standards for Dialysis Adequacy.

Deprescribing the Kt/V Target for Peritoneal Dialysis in the United States: The Path Toward Adopting International Standards for Dialysis Adequacy.

BPJS Claims Pending Case Coding Training at AISYIYAH PADANG RSU

Hospital health facilities are required to complete BPJS claim documents before submitting them to BPJS Health to get reimbursement for treatment costs according to the Indonesian Case Base Groups (INA-CBG's) rates. The BPJS claim process already uses the INA-CBGs program. With this payment method, the accuracy of clinical and procedure code data determines the financing of health services. Service of Community Activities (PKM) aim to provide education regarding ICD-10 coding regulations in minimizing cases of pending claims that occur at Aisyiyah General Hospital, Padang. This PKM did at Aisyiyah Hospital Padang on 06-07 October 2022 Service of Community in the form of outreach regarding the urgency of using the ICD-10 then followed up in the form of practicing ICD-10 coding cases of pending claims to partners. This activity was attended by 18 participants from the medical team and case-mix. Result of pre-test and post-test showed, increasing the team's understanding of ICD-10 coding regulations and cases pending claims.

Notified occupational mental disorders: associations with health and income.

Studies indicate that workers' compensation claim processes may affect patients' health negatively. However, few studies focus on patients with mental health claims, and the claim process varies between countries. The aims of this study were to examine whether being notified to the Danish Labour Market Insurance with an occupational mental health condition was associated with changes in visits to the general practitioner (GP), use of medicine and annual income. Study participants were 965 patients with a mental disorder examined at a department of occupational medicine. Of these, 669 patients were notified with an occupational mental disorder, 296 were not. Health-related outcomes, including GP visits and prescriptions of psychotropic drugs, were estimated at baseline during the year of medical examination, while annual income was estimated a year before the examination. The follow-up was the year after the year of examination for all outcomes. Outcomes were collected from the Danish National Bureau of Statistics. Analyses were conducted using Poisson regression and conditional logistic regression. All measured outcomes decreased from baseline to follow-up in both groups. These changes were not significantly different depending on notification status at baseline. This study suggests that being notified with an occupational mental disorder does not significantly affect health-related outcomes. A significant decrease in annual income over time was seen in both groups, the notified and the unnotified group, highlighting the importance of providing support to all employees with a mental disorder.

Gambaran Proses Klaim Covid–19 Orang dengan Gangguan Jiwa Ke Kementerian Kesehatan di RSJ Soeharto Heerdjan Tahun 2020-2021

In the beginning of 2020, the world is shocked with the outbreak of a new virus that is a new strain of Coronavirus (SARS-CoV-2) the disease itself is called Coronavirus disease 2019 (COVID-19). COVID-19 is infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus 2. This disease spread throughout the world including Indonesia. COVID-19 could infect anyone including mentally ill people, because of high infection rate in Indonesia it become an emerging disease where the payment is done by government so the funds can be claimed in Ministry of Health, the claim could be done by referenced hospital that provide service for emerging disease patient including dr.Soeharto Heerdjan Mental Hospital. The aim for this research is to look for the process of COVID-19 claim for mentally ill people to Ministry of Health in dr.Soeharto Heerdjan Mental Hospital. The research method is descriptive qualitative. Data collection gained from interview and observation. Research result data suggest that dr.Soeharto Heerdjan Mental Hospital hasn’t own SPO for Covid-19 claim so that implementation process refers to Ministry of Health’s decision. Covid-19 claim process in dr.Soeharto Heerdjan Mental Hospital started when the patient has obtained inpatient hospitalization, then the status is verified by verificator doctor, then the files is sent to casemix for completion verification of the files until it’s submitted to BPJS and the Ministry of Health. The obstacle for Covid-19 claim process for mentally ill people in dr.Soeharto Heerdjan Mental Hospital among others are incomplete medical resume fulfillment, and disorder of e-claim system. Better to make detailed SPO regarding Covid-19 claim to Ministry of Health. It's advised to evaluate and review doctors to complete medical resume, and give warnings to doctors that still write incomplete medical resume.

The experience of claiming mental health disability benefits: A qualitative analysis of clients' perspectives.

INTRODUCTION: The decision to apply for disability benefits may be an important breakthrough in the life of those diagnosed with severe mental illness (SMI). Nevertheless, the literature regarding the application process is scarce. The aim of the study was to explore how people who receive mental health disability benefits retrospectively perceive the process of applying for and receiving these benefits. Twenty-four in-depth qualitative interviews were conducted with people whose mental health disability was recognized in the past few years. Analysis revealed three themes describing the process's chronological stages: Before submitting the claim (from deterioration to trust), during the claim process (from bureaucracy to understanding), after receiving recognition (from stigma to gratitude). Each stage includes facilitating factors (e.g. encouragement from professionals) and hindering factors (e.g. stigma, lack of knowledge and trust). This is the first study to fully describe the experience of applying for mental health disability benefits, as experienced by clients. The decision to apply is perceived as complex and difficult. Although clients are extensively preoccupied with stigma throughout the process, they are able to express gratitude for the opportunities made available to them. Professional assistance throughout the claim is a key factor with the potential to change clients' experience of the entire process.

Optimal insurance contracts for a shot-noise Cox claim process and persistent insured's actions

We consider a continuous-time model in which an insurer proposes an insurance contract to a potential insured. Motivated by climate change and catastrophic events, we assume that the number of claims process is a shot-noise Cox process. The insurer selects the premium to be paid by the potential insured and the amount to be paid for each claim. In addition, the insurer can request some actions from the potential insured to reduce the number of claims. The insurer wants to maximize his expected total utility, while the potential insured signs the contract if his expected total utility for signing the contract is greater than or equal to his expected total utility when he does not sign the contract. We obtain an analytical solution for the optimal premium, the optimal amount to be paid for each claim, and the optimal actions of the insured. This leads to interesting managerial insights.

ASURANSI BPJS TINJAUAN PELEPASAN INFORMASI REKAM MEDIS UNTUK KLAIM ASURANSI BPJS KESEHATAN DI RSUD KANJURUHAN KEPANJEN

Payment is a very important activity in a hospital. One way of payment of health care in hospital is BPJS of health. Issues contained in the release of medical record information for insurance claims BPJS of health in Kanjuruhan Kepanjen Hospital is not yet completed the requirements of the claims, especially the summary sheet and the sheet out the verification and dissemination SOP has been no release of medical record information for insurance claims BPJS of health. The research method in this study using descriptive research method. The results showed that participants BPJS of health insurance in the first quarter 2019 in Kanjuruhan Kepanjen Hospital is the highest number of patients with a percentage of 61% of the 3,553 inpatients. Problems that hinder the process of insurance claims is not yet complete BPJS claim requirements, especially the summary sheet out and verification with a percentage of 28.12% in January, 36.26% in February and 36.08% in March, another problem is the lack of socialization to the SOP involved in the release of medical record information primarily to the medical staff who are in the inpatient unit.
 
 Keywords: Insurance, BPJS of health, Release, Medical Record

Some observations on the temporal patterns in the surplus process of an insurer

Abstract In this paper, we explore potential surplus modelling improvements by investigating how well the available models describe an insurance risk process. To this end, we obtain and analyse a real-life data set that is provided by an anonymous insurer. Based on our analysis, we discover that both the purchasing process and the corresponding claim process have seasonal fluctuations. Some special events, such as public holidays, also have impact on these processes. In the existing literature, the seasonality is often stressed in the claim process, while the cash inflow usually assumes simple forms. We further suggest a possible way of modelling the dependence between these two processes. A preliminary analysis of the impact of these patterns on the surplus process is also conducted. As a result, we propose a surplus process model which utilises a non-homogeneous Poisson process for premium counts and a Cox process for claim counts that reflect the specific features of the data.

Non-zero-sum reinsurance and investment game with correlation between insurance market and financial market under CEV model

<p style='text-indent:20px;'>In this paper, we study a non-zero-sum investment and reinsurance game for two insurers. Each insurer's surplus process is described by a Brownian motion with drift. Both insurers are allowed to purchase proportional reinsurance and invest in a risk-free asset and a risky asset. The price process of the risky asset follows the constant elasticity of variance (CEV) model, and the correlation between the risky asset's price process and the claim process is considered. Each insurer aims to maximize the expected exponential utility of his terminal wealth relative to that of his competitor. By applying stochastic control theory, we establish the corresponding Hamilton-Jacobi-Bellman (HJB) equation and derive optimal investment-reinsurance strategies for two insurers under exponential utility function. Furthermore, we consider the insurer's optimal investment-reinsurance strategies without competition. Finally, numerical analyses are provided to analyze the effects of model parameters on the optimal strategies.</p>

10 important financial investments for orthopods in India

10 important financial investments for orthopods in India

On the formulation of a stochastic model for an accumulated claim amount under renewal risk process

Traditionally an Insurance risk process is characterised by claim process using renewal process assuming claim amount is independent of inter claim time. It is usually modelled as a stochastic process such as Compound Poisson Process. It is also assumed that the premium amount is proportional to the time we refer with each claim. Depending upon the type of portfolio, the insurer can make a variety of different assumptions on the sequence of inter occurrence times and accumulated claim amount as well. In this paper we discuss a stochastic model for Renewal Risk model with different distributions to number of demands and Generalised Exponential distribution to the impact of each demand under insurance claim scenario. Assume that number of cases is independent of severity of each case throughout the model. We present the model when case frequency is Poison or Negative Binomial or Geometric and also present severity of each case with Generalised Exponential distribution.

Optimal reinsurance-investment problem for a general insurance company under a generalized dynamic contagion claim model

<p style='text-indent:20px;'>In this paper, we study an optimal management problem for a general insurance company which holds shares of an insurance company and a reinsurance company. The general company aims to derive the equilibrium reinsurance-investment strategy under the mean-variance criterion. The claim process described by a generalized compound dynamic contagion process introduced by [<xref ref-type="bibr" rid="b18">18</xref>] which allows for self-exciting and externally-exciting clustering effect for the claim arrivals and the processes of the risky assets are described by the jump-diffusion models. Based on practical considerations, we suppose that the externally-exciting clustering effect will simultaneously affect both the price of risky assets and the intensity of claims. To overcome the inconsistency issue caused by the mean-variance criterion, we formulate the optimization problem as an embedded game and solve it via a corresponding extended Hamilton-Jacobi-Bellman equation. The equilibrium reinsurance-investment strategy is obtained, which depends on a solution to an ordinary differential equation. In addition, we demonstrate the derived equilibrium strategy and the economic implications behind it through a large number of mathematical analysis and numerical examples.</p>

How's the recovery? Salvage and subrogation in the property liability insurance industry

Insurers have significant flexibility in the management of the claims process and the degree to which they prioritize the collection of salvage and subrogation. These decisions could materially impact the financial well-being of insurers as well as the prices paid by consumers. Given the potential implications that salvage and subrogation can have for insurers, consumers, and regulators, we investigate the relation between the speed at which U.S. property-liability insurers recover salvage and subrogation and insurer-specific financial and operational characteristics. The analysis is conducted for commercial and personal auto lines of business and studies both physical damage and liability coverages. The findings indicate that factors such as leverage, profitability, size, and accrual decisions are associated with the speed of recovery but that considerable differences exist across coverages.

Optimal investment and reinsurance for the insurer and reinsurer with the joint exponential utility under the CEV model

<abstract><p>This paper considers the problem of optimal investment-reinsurance for the insurer and reinsurer under the constant elasticity of variance (CEV) model. It is assumed that the net claims process is approximated by a diffusion process, both the insurer and reinsurer can invest in risk-free assets and risky assets. We use the variance premium principle to calculate the premiums of the insurer and reinsurer, and the reinsurance proportion is constrained by the net profit condition. Our objective is to maximize the joint exponential utility of the insurer and reinsurer's terminal wealth for a fixed time. By solving the HJB equation, we obtain the explicit expressions of the optimal investment-reinsurance strategy and value function. We find that the optimal reinsurance strategy can be divided into many cases and is related to the risk aversion coefficient of the insurer and reinsurer, but independent of the price of risky assets. Furthermore, we give the proof of the verification theorem. Finally, we demonstrate a numerical analysis to explain the results.</p></abstract>

Robust equilibrium reinsurance and investment strategy for the insurer and reinsurer under weighted mean-variance criterion

<abstract><p>This paper investigates the time-consistent robust optimal reinsurance problem for the insurer and reinsurer under weighted objective criteria. The joint objective criterion is obtained by weighting the mean-variance objectives of both the insurer and reinsurer. Specifically, we assume that the net claim process is approximated by a diffusion model, and the insurer can purchase proportional reinsurance from the reinsurer. The insurer adopts the loss-dependent premium principle considering historical claims, while the reinsurance contract still uses the expected premium principle due to information asymmetry. Both the insurer and reinsurer can invest in risk-free assets and risky assets, where the risky asset price is described by the constant elasticity of variance model. Additionally, the ambiguity-averse insurer and ambiguity-averse reinsurer worry about the uncertainty of parameter estimation in the model, therefore, we obtain a robust optimization objective through the robust control method. By solving the corresponding extended Hamilton-Jacobi-Bellman equation, we derive the time-consistent robust equilibrium reinsurance and investment strategy and corresponding value function. Finally, we examined the impact of various parameters on the robust equilibrium strategy through numerical examples.</p></abstract>

The Transformative Potential of Artificial Intelligence in Medical Billing: A Global Perspective

This paper explores the transformative potential of Artificial Intelligence (AI) in revolutionizing medical billing processes worldwide. As healthcare systems face increasing complexities and challenges, AI offers innovative solutions to streamline billing operations, enhance accuracy, and improve financial outcomes. By automating the claims processing workflow, AI can significantly reduce the administrative burden on healthcare providers, allowing them to focus more on patient care. AI-powered coding accuracy systems can analyze medical records and suggest appropriate billing codes, reducing coding errors and claim rejections. AI can also optimize reimbursement strategies by analyzing historical data and identifying patterns to ensure optimal reimbursement rates for healthcare providers. To address the growing concern of healthcare fraud, AI algorithms can analyze vast amounts of data, detect suspicious patterns, and flag potentially fraudulent activities, thus preventing financial losses. Moreover, AI-powered chatbots and virtual assistants can enhance patient engagement by providing personalized support, answering billing-related queries, and guiding patients through the payment process. Adoption of AI in medical billing brings various benefits, it also presents challenges such as data privacy, algorithm bias, and the need for robust infrastructure and training. Successful case studies from various healthcare settings worldwide demonstrate the tangible advantages of AI implementation, such as reduced billing errors, accelerated reimbursement cycles, and improved patient satisfaction. By harnessing the power of AI, healthcare systems can achieve greater efficiency, financial sustainability, and improved patient experiences.

Behavior Analysis of Farmers in Tidal Swamp Land towards Agricultural Insurance

In many studies, communication and social cognitive theories have been used to investigate people’s behaviors toward agricultural insurance programs resulting in varied conclusions on how and why people react to such programs. However, few of them have explicitly investigated the role of social cognitive theory in escalating insurance literacy levels on agriculture and cultural factors. Thus, the purpose of this study is to identify and analyze the behavioral factors of tidal swampland farmers in Barito Kuala Regency, South Kalimantan province, towards agricultural insurance in the perspective of analyzing farmers' knowledge of agricultural insurance products and determinants of community behavior. Under the instrumental case-study research design, the data were collected through interviews and Focus Group Discussion (FGDs) with 35 informants, consisting of the Head of the South Kalimantan Provincial Agriculture Service and the Barito Kuala District Agriculture Service, opinion leaders, academics, representatives of farmer groups, and farmers. Documentation data related to the implementation of the agricultural insurance program were used to complete the interview and FGDs data. The results of this study indicate that tidal swampland farmers are trapped in hoax information or negative issues related to Agricultural Insurance which makes them reluctant to participate in agricultural insurance. Farmers prefer to be resigned and surrender to the state of their agricultural land than to participate in agricultural insurance. Besides, farmers feel there is no point in participating in agricultural insurance, especially those who think the registration and insurance claim process is convoluted. Low insurance literacy is a key problem of the misinformation that is formed.

Asymptotics for the random time ruin probability with non stationary arrivals and Brownian perturbation

In this paper, we consider a risk model with heavy-tailed claims and Brownian perturbation. Assuming that the distribution function of claim-size is subexponential, and the arrival process of claims is a non stationary process satisfying the principle of large deviation, the asymptotic formula for the ruin probability of this risk model at random time is obtained.