Claims, which represent the proportion of claims (complaints or requests for reimbursement) in relation to the total value of premiums received by a health insurance company, is one of the main indicators of performance and financial sustainability in the supplementary health sector. Reducing accidents is essential for the economic viability of health insurance companies and for keeping health plans affordable. Below, we discuss some effective strategies that a health insurance company can adopt to reduce claims.

1. Health Promotion and Disease Prevention

Health promotion and disease prevention are key to reducing claims. Investing in wellness programs, vaccination campaigns, regular check-ups and chronic disease monitoring programs can reduce the incidence of serious complications and, consequently, high-cost claims. For example, diabetes management programs that closely monitor patients can prevent hospitalizations and complications, reducing significant costs in the long term.

2. Case Management and Chronic Diseases

Implementing effective case and chronic disease management is another crucial strategy. This involves proactively identifying high-risk members and providing coordinated, personalized care. Nurses, social workers and other health professionals can act as case managers, helping to ensure that patients follow treatment plans, attend regular appointments and adopt healthy behaviors. Managing chronic diseases, such as hypertension and heart disease, can significantly reduce the need for emergency treatment and hospitalizations.

3. Use of Technology and Big Data

The use of technology and big data analysis can transform the way operators manage claims. A data analysis allows the identification of patterns and trends that can predict future claims. Predictive analysis tools can help identify members at risk and implement preventive interventions. In addition, telemedicine and health monitoring applications allow closer and continuous monitoring of patients, increasing adherence to treatments and reducing the need for more expensive interventions.

4. Negotiating and Auditing Service Providers

Effective negotiation with healthcare providers is essential for controlling costs. Establishing contracts with performance clauses and results-based incentives can align providers' interests with those of the operator. In addition, regular audits of service providers can identify and eliminate fraud and waste. The implementation of preferred provider networks, which offer quality services at lower costs, can also be an effective measure.

5. Beneficiary Education and Engagement

Educating and engaging beneficiaries is an underestimated but powerful strategy. When beneficiaries better understand their health plans and the costs associated with different types of care, they can make more informed and cost-effective decisions. Education programs that explain the importance of using preventive services, avoiding unnecessary emergency room visits and choosing in-network providers can contribute to reducing claims.

6. Incentives for Healthy Behaviors

Offering incentives for healthy behaviors is an increasingly adopted practice. Discounts on insurance premiums, rewards for health goals achieved, such as weight loss or smoking cessation, and the offer of fitness programs are examples of how to encourage beneficiaries to adopt healthier lifestyles. Healthy behaviors result in fewer illnesses and therefore fewer claims.

7. Improved Patient Experience

Finally, continuous improvement of the patient experience can have a positive impact on claims. Facilitating access to quality healthcare, reducing waiting times and improving communication between patients and service providers can increase patient satisfaction and encourage the appropriate use of healthcare services.

Reducing accidents is a priority

Reducing claims is a multifaceted challenge that requires a comprehensive and integrated approach. By promoting health and preventing disease, managing cases effectively, using advanced technologies, negotiating and auditing service providers, engaging and educating beneficiaries, offering incentives for healthy behaviors and improving the patient experience, health insurance companies can achieve a significant reduction in claims, ensuring financial sustainability and offering quality services to their beneficiaries.

And if we tell you that he has a medical bill audit system which, in addition to automating processes, helps you put almost all the points presented in this article into action? It's a system adopted by dozens of health insurance companies throughout Brazil. It's also the most awarded. Read on and see a case of great success!

Understand why SAUDI reduces your healthcare provider's claims rate in the first 3 months of use:

Automate medical and administrative audit processes electronically, quickly and reliably;

Optimize process flows by identifying and eliminating bottlenecks;

Eliminate 100% the use of paper from your operator's processes;

Zero implementation costs;

Automate medical and administrative audit processes electronically and quickly;

Reduction of accidents, through a marked improvement in claims controls and better contractualization of the provider network.

Are you interested? Wait until you know all the advantages of SAUDI system! Book an appointment free demo no obligation right now! ; )

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