Managing a health plan operator is always a challenge, even more so in a country like Brazil, where the legislation itself is still improving in this segment and even managers may have important doubts about the topic. Therefore, it is essential to understand what the health plan's claims ratio is and how to improve its indicators.

This is a subject that needs to be clarified very well, since inadequately carrying out procedures considerably increases an operator's costs and can even make it financially unviable. Check out the content below and find out how to avoid this.

What is the accident rate?

For the health operator, the accident rate is the actual accounting of the occurrence of accidents, which, in this case, are the number of claims made by customers. This makes up the relationship between costs (claims) and revenues, which are premiums. This total needs to be calculated and subsequently represented by a rate or percentage.

This topic has been debated, above all, due to the excessive and unrestrained carrying out of consultations and exams by beneficiaries, the need for which is not always evident, compromising the company's financial management, as well as increasing the costs of maintaining medical plans, in a vicious circle.

If people learn a little more about the subject and understand how their actions have a high impact on the price they themselves pay, it is natural that they will feel motivated to collaborate, having more parsimony in their choices and, in this way, contributing to the reduction of readjustments in health plans.

What affects the claims rate in a health plan?

As we said above, beneficiaries play a fundamental role in whether or not health insurance companies' accident rates are balanced. However, this is not the only influencing element in this context, which is also changed by other factors. Check out some of the main ones below:

Frequency of use

One of the factors that most affect the claims rate in a health plan is, as we said, the frequency of use. And this not only concerns the number of unnecessary consultations carried out by beneficiaries, but also inadequate therapies, unnecessary exams, as well as unnecessary hospitalizations and surgeries.

It is worth remembering that this is not always the exclusive fault of uninformed or hypochondriac patients, but also of professionals who do not have the necessary technical qualifications to perform their functions or, possibly, who are committing fraud, increasing the value of the claim.

Unforeseen events and calamities

Another cause that, although rarer, also affects the accident rate in a health plan is the occurrence of unforeseen events, especially some calamity or catastrophe in a place that has many beneficiaries of a certain operator. Undeniably, an abrupt increase in the number of claims impacts the financial situation of any company in the sector.

The concomitant occurrence of several high-cost cases, generally resulting from serious accidents or natural disasters, greatly increases the number of admissions to long-stay ICU beds and also surgical procedures, which are highly expensive, especially for long periods.

The judicialization

The use of judicial means to cover treatments not provided for by contracts.

New technologies

The inclusion of new diagnostic methods or treatments not provided for in contracts, whose coverage is generally imposed, either by the Regulatory Agency, by the attending physician, or by the courts.

Value of prizes

A high premium value is also a relevant reason, which certainly greatly affects the loss rate in a health plan. Imbalances are very common in this market. Prices may be above or even below what is necessary to cover the healthcare costs of the contracted network.

Some companies in the sector adopt a practice called dumping, which is potentially harmful and aims to quickly grow the portfolio, without considering its profitability in the future. In these cases, it is essential to carry out a audit or a detailed study of the financial reality of the market, otherwise, the bill will arrive at the next adjustment.

How to improve the health plan’s claims ratio?

Master the available information

The first step to improving the health plan's claims ratio is to master the large amount of information available. This is even more fundamental in the current scenario in Brazil, in which the population continues to move towards increasing longevity, constituting a larger contingent of elderly people.

This should increase the demand for specific portfolios, which offer good alternatives for those in old age. Therefore, the best operators need to deal with this increase, managing data better and preventing a large volume of procedures from compromising the company's management and financial organization.

Offer coherent plan options

As we saw above, the accident rate correlates revenues and expenses, which are, respectively, the value of the monthly fees received with the expenses generated by the assistance that was made available to users. And if it is precisely this contrast that determines the operator's financial balance, keeping it under control is essential.

One of the ways to do this is by encouraging preventive care and offering plan options that are coherent from an economic point of view. It is feasible to implement moderators in the use of services, aiming to restrict the indiscriminate use of consultations, exams, procedures and surgeries, for example.

Bet on a technological solution

When betting on a software management system aimed at health plan operators, you can automate processes and have much more dynamic and reliable control over the number of beneficiaries. You gain simple access to the records of each profile, being able to carry out preventive actions.

Knowing your customer and their providers in depth has become essential for effective cost control for operators.

This way, it becomes much easier to plan, implement and evaluate your policies, which leads to positive and immediate results, but especially in the medium and long term, significantly improving the control of your accident rate. Believe me: the results can be surprising in the first few months of use!

As you can see, improving the health plan's claims ratio is a fundamental attitude to improve your indicators in the short, medium and long term. This way, you can have much more efficient processes and, thus, gain prominence in this highly sought after segment of the market!

Did you enjoy learning a little more about health plan claims? Do you want to count on a highly efficient technological solution for companies based in this market? So don't waste any more time and get in touch with SAUDI!