Five categories of focused questions every prospective expatriate medical insurer should be asked
I. Integration of medical assistance services
Can our members call your company 24/7 with a medical question in any language and speak directly with a knowledgeable physician?
Immediate access to a knowledgeable medical professional is key to quickly assessing the condition and needs of the expatriate with medical concerns. It also gives confidence and reassurance to the member that they aren't facing a serious situation alone. While a nurse may also be able to provide similar results, a physician may be more inclined to provide self-treatment advice and will have an easier peer-to-peer communication if a conversation with the member's local treating doctor or referral doctor is required.
Which assistance company do you use and what is their experience with providing assistance services?
The assistance industry has its share of the very good, the very poor and the untested. Additional probing may be appropriate to understand the vendor's true capability and experience, such as: what percentage (and number) of its cases occur outside of North America (e.g., is most of its international case activity composed of Canadian snowbirds?); describe the size, location and background of the medical staff employed by the assistance company; and, is medical assistance focused on expatriates a core, long-term offering or is this a recent diversification from seemingly related services (e.g., the international equivalent of AAA or in-flight medical advice)?
It takes a substantial amount of repetitive medical case activity to build up worldwide resources and a knowledge base.
Describe the degree to which the assistance company is integrated into your service, provider network, utilization and healthcare processes.
Typically the more integrated, the better. This avoids silos and workflow that can result in misrouted or overlooked requests for help, eliminating opportunities for error. On the other hand, you don't want an operation that totally delegates core services to a vendor without adequate oversight.
What medical assistance services are included in your basic service offering?
Some carriers bundle certain medical assistance services in their core offering while others make this a fee-for-service option. Indemnified evacuation and repatriation services are often an option.
If we have evacuation coverage through another vendor, will you carve evacuation out of our coverage and provide a corresponding reduction in rates?
Your company may have separate evacuation coverage through a medical assistance provider for your travelers and expatriates, Business Travel Accident policy, etc. Some carriers may not be willing to unbundle evacuation from their core offering, meaning you're effectively paying for double-coverage.
II. International provider network
That types of providers are in your international provider network and are they all visible in a directory accessible by the member?
Does the carrier provide a directory of their international network providers to their members? If so, do they provide some guidelines to the member on how to most appropriately use the network? For instance, the appearance of specialists on a directory accessible by the member may imply the carrier is happy for members who believe they require specialty care to simply self-refer to a specialist without any assistance or guidance by a medical professional. While this isn't necessarily a concern in developed countries, it is a considerable concern in under-developed countries. A member with current symptoms is best served by receiving a real-time medical assessment so that the most appropriate provider/specialist can be determined.
Describe the selection criteria and process employed for providers to be listed on your international provider directory.
This may be the most important question you can ask of a carrier that provides such a directory. Around the globe there is no single, commonly used qualification or accreditation standard or process. Within the industry there is a range of responses to such a question. On the low end of the scale is a directory that utilizes no specific selection criteria and is simply a directory of known providers, similar to the phone book. A mid-range response would be a process involving simple recommendations from various external parties with subjective/anecdotal qualifiers. Examples would include: embassy recommendation, airline /hotel recommendation, or American board certification/Royal College of Medicine certification. The higher end range involves a number of objective criteria regarding the provider's training, experience, and documented history with the carrier or carrier's assistance company. On-site evaluations by medical professionals represent the "gold standard
Do all of the providers with whom you have contracts or formal arrangements meet your provider selection criteria?
This will demonstrate how seriously the carrier takes their own selection criteria.
Do you use brokers or other independent intermediaries to negotiate discounts with international providers?
It's not uncommon in the industry for a carrier to use an independent intermediary to negotiate discounts. The intermediary brokers arrangements whereby a number of purchasers may consolidate their purchasing power; however, there are risks to this approach. The carrier may lack controls and data necessary to ensure discounts represent actual savings, which can create an opportunity for providers engaged in such relationships to inflate charges to offset the discounts. When the intermediary's fee (e.g., percent of savings, etc.) is added, the result may be a net increase in charges for the carrier. All the while the carrier believes they are enjoying discounted pricing.
What is the basis for your international provider discounts (e.g., discount off billed, fee schedule, DRG, etc.) and what is the resulting effective range of discounts with international providers? Are all of the savings generated from these discount arrangements passed along to your ASO clients?
The most common form of discount, where discounts exist, are percent off billed charges. While having less predictability than other forms, the carrier can add controls such as having data on the provider's normal schedule of fees. Clearly, passing the carrier's savings to ASO and dividend eligible clients is preferable. You should also confirm whether the member enjoys any discounts on their coinsurance.
III. Making payments directly to international providers
Do you provide guarantees of payments to international physicians, dentists and clinics?
Some carriers will only provide guarantees of payment to international hospitals for inpatient care. Others will honor assignment of benefits to non-institutional providers but will not actually provide a guarantee of payment in advance of services. Some of the carriers will only make guarantees of payment to a limited number of facilities with whom they have existing contractual relationships. Finally, some carriers will administer guarantee of payments to any international provider.
How many different claim forms do you maintain?
Some carriers have claim forms for each and every line of coverage, while others have a single form. What languages are the forms available in?
Is a completed claim form required with every international claim submission?
Some carriers insist that a claim form be sent with every claim submission. Others will insist on at least one completed claim form for each member annually. The most liberal approach is to not require a claim form as long as the submitted documents contain all of the necessary data elements required to resolve the claim.
What is the process and timeframe for a member to request a guarantee of payment to an international physician and hospital?
Lead times range from no required advance notice to at least 10 days advance notice. Requiring any advance notice limits the use of guarantees of payment in emergency situations. Adding financial concerns on top of a medical emergency is not conducive to a beneficial outcome.
What percentage of your international benefits are paid directly to providers?
This is a good question to ask in order to differentiate the approaches and success carriers have with paying benefits directly to international providers and alleviating members from the pain of "pay and claim."
What tools or approaches do you employ if a provider does not accept a guarantee of payment from your company?
Does the carrier simply give up or do they have other mechanisms for meeting the financial requirements of an uncooperative provider? International providers have a long history of being burned by insurance companies, so it isn't unusual for them to be skeptical.
IV. Composition and experience of the medical staff performing international care monitoring and case management
Who are the staff who perform international medical monitoring and care management? Where are they located? What is their international clinical experience?
Beware of a US-centric set-up. While the value of US nurses is clearly understood within North America and many European countries, a US-based nurse may not have the professional stature in the eyes of providers in the rest of the world required to get the cooperation of the treating doctor. The most effective care managers not only receive information, but provide information and professional suasion to steer treatment plans to optimal outcomes. Has the staff ever practiced medicine abroad? Do they understand the nuances of medicine as delivered in all of the locations you have staff?
If you outsource this function, what process do you employ to oversee their work? What is the international clinical experience of the person(s) within your organization who perform this oversight?
It's not unusual or undesirable for a carrier to outsource international medical monitoring and care management. This may enable the carrier a greater footprint, local knowledge and service capabilities; however, it is key for the carrier to have an effective program to manage the vendor. A medical professional with actual international clinical experience is preferable.
Do you employ a full-time international medical director? What is his/her international clinical experience?
Few carriers have a full-time international medical director, much less one with international clinical experience. The presence of such a position may indicate a the carrier's commitment to the quality medical care its members receive.
Describe the international clinical experience of any nurses you employ.
Nurses who have first-hand experience with delivering care internationally will have greater success with obtaining information and providing appropriate advice to treating doctors.
V. Innovative health programs for the global population
What innovative health management programs are you developing to serve our population? Are such programs part of your basic service offering or do they require additional fees?
The carrier should describe their vision of where the industry is currently headed, and what programs they're creating to ensure they are among the leaders. Are these programs simply opportunities for additional fees or do they strengthen the value proposition of the carrier's entire portfolio?
Call Jack Mann if you have questions.
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