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New guidelines issued for health insurance claims management

Key significance: Regulations will reduce potential for discrepancies and disputes between insurance companies and private health institutions
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The Capital Market Authority (CMA) has issued a decision for the management of the health insurance claims revenue cycle.

Decision 107/ 2022 organises the documentary cycle and provides the service of filing, following up and processing of insurance claims on behalf of the health service provider. The regulation includes the necessary rules to licence health insurance claims revenue cycle management companies in the Sultanate of Oman.

Ahmed bin Ali al Maamari, Vice President - Insurance Sector, said the regulation is part of preparations for the implementation of the compulsory health insurance scheme (Dhamani) for the employees of the private sector and visitors to the Sultanate of Oman.

With this new regulation, the legislative requirements of the all parties that are stakeholders in the health insurance process are now complete.

“This initiative will also contribute to improving the quality of health insurance claims sent to insurance companies, verifying their compatibility with the medical coding system, reducing differences and disputes between insurance companies and private health institutions as a result of rejected claims and nonpayment.

He said that the introduction of this type of activities in the insurance market will contribute to expanding the role of the insurance sector to accommodate the graduate of educational institutions, as well as providing technical and administrative job opportunities, whether in the disciplines related to health sciences or accounting, finance and administration and information systems,” the Vice President said.

According to the regulation, the activity will provide many services to private health institutions, related to managing the documentary cycle, providing medical coding services, billing, revenue development, technical, financial and advisory services, as the company will be concerned with verifying the identity of the insured and eligibility for treatment services further to transferring treatment services to billable fees, processing rejected claims, knowing the source of the problems of rejected claims and working to correct them, in addition to sending health insurance claims electronically to insurance companies or health insurance claims administrators, and ensuring that they receive those claims according to the specified timeframes.

The company will also be responsible for following up the collection of funds for treatment services provided to health insurance policyholders, as well as training and qualifying the employees of private health institutions to use the approved medical coding systems or the systems that may be introduced in the future.

The importance of private health institutions contracting with health insurance claims revenue cycle management companies is to raise the quality of health insurance claims that will be sent to insurance companies or health insurance claims administrators, reduce administrative and operational costs for private health institutions, and reduce health insurance claims rejected by Insurance companies or health insurance claims administrators, in addition to improving and simplifying the operational procedures of private health institutions, and ensuring the financial stability of the private health institution.

According to the audited financial statements of the insurance sector, health insurance premiums rose 5.6 per cent to RO 164 million in 2021, and the value of compensation related to health insurance activity dipped 0.5 per cent to RO 120 million. The data also showed an increase in the health insurance policies by 88 per cent to 23,000 policies.

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