Insurance pre-approvals causing huge delays for patients in the UAE

Dubai: All of 79 minutes — that is the average time spent by a patient at a hospital or a clinic in the UAE during a visit these days. Now, here’s the bitter pill — nine minutes is all that he or she actually gets with a doctor for the check-up procedures.

The rest of the time is taken up clearing the formalities leading up to the point where the patient meets the doctor. These steps are taking longer and longer, as health care operators work with medical insurers to find out what sort of care the patient is entitled to and how much it should cost

The 79 minutes only cover the point from the patient’s entry into the hospital and clinic to paying his or her share of the bill. It does not take into account the trip to the pharmacy to collect medicines.

Making these revelations, Jobilal Vavachan, CEO and Vice-president at the Aster group, said, “These are based on a study we did internally last year and I believe the time spent has shot up quite dramatically during this period. In 2016 or 2017, the average time would have been around 45 minutes.”

Other hospital networks in the UAE Gulf News spoke to also said it is taking longer for patients now to seek advice for their ailments. Even specialist clinics are burdened by the longer tenure of these visits.

Health care providers are unanimous in what’s causing the clogging — the time they spend “taking pre-approvals” from insurers for each step in the treatment process. So, if a patient walks in to see a specialist, hospitals/clinics insist on them first being checked by a general physician and only then being passed on to the specialist, if necessary.

“In the past a patient could come directly and seek the consultant,” said Vavachan. “It’s not that easy any more — everything is being duplicated in a way.

“An eligibility check needs to be performed before the consultation. We have to take approval from the insurer before doing any procedure. Insurers too have lost a lot of money in the last one year or so on their medical policies, especially those administering low-end health insurance. They have in turn put the pressure on hospital operators on each procedure involved in the treatment … With approvals taking time, the person who suffers is the end-user. He has to wait for an approval right from consultation and lab test to getting the medicines.”

So, what has led to this point?

Industry sources say this is the natural outcome of medical cover becoming compulsory in Dubai and Abu Dhabi. In Dubai, first two years after this came about saw newly insured residents making a beeline to hospitals and clinics. Their belief was that insurance would take care of everything … but not for too long.

By 2017, insurers realised that their medical lines were starting to hurt them, and in 2018, they were starting to bleed financially. After two record years of issuing policies and collecting premiums, they were hit with a stark reality.

In a difficult economy, employers were forced to drive hard bargains with insurers in ensuring coverage for their employees. Group policy benefits were often cut across the board so that premium costs could be brought down.

Then again, the premiums insurers set were too low to sustain their businesses in the longer term. They started to enforce upper limits on what their policies could provide; so someone with a EBP (Essential Benefits Plan) that costs Dh600 a year can only access medicines totalling up Dh1,500-Dh2,000 a year. An individual on a low-end coverage can access up to Dh5,000 worth of prescribed medicines a year.

Mark Adams, CEO of The Healthcare Network, suggests that tough decisions need to be made, and fast.

“As the market consolidates and fewer insurers work more professionally with fewer health care providers, the situation will ease,” he said. “Capitation” is one solution which is used in Dubai today, but not allowed in Abu Dhabi.

“If clinics are paid a fixed amount per month per patient to cover all consultations, minor treatment and diagnostics, the clinic has no incentive to over treat. Indeed, there is likely to be a move to more preventive treatments and therapies.

prescribing, it is possible to agree on improved terms with insurers that could include payments-on-account. This would, however, require very different relationships that tend to exist today.” (Payments on account are essentially those made in advance before the set deadline.)

Has market dynamic reached a point where health care providers and insurers need to come up with a set of solutions before it reaches breaking point? Or is it something for health care authorities to intervene and enforce?

According to Anil Nair, CEO of Iris Health Services, “This is not only a payer’s issue — Insurance companies, TPAs (third-party administrators) and medical service providers each have to take steps to improve clarity, accuracy and efficiency to eliminate the strain in the system. While medical service providers, for example, need to submit complete claims information to the payers on time, payers also need to revert with timely responses to providers.

“There is no doubt that costs of treatment have risen while premiums are at their lowest or stagnant. Abu Dhabi, for example, has increased the premium for enhanced EBP (Essential Benefits Plan). There is an urgent need for an increase in premiums to ensure proper coverage, better community health, and the sustainability of the health insurance sector.”

That the UAE’s health insurance sector could do with a cure is something everyone agrees on. It’s the prescription that they are waiting for.

DUBAI: Building a new hospital or clinic in the UAE is the easy part these days. But ensuring insurers will include them in the coverage is the tricky part.

This is how it works: In their group policy agreements with employers, insurers clearly stipulate that those insured can only seek consultation or treatment at pre-approved hospitals or clinics. So, for a new health care facility, it is important that it is on that pre-approved list to have enough people coming to it. And it needs to be on the list as soon as it opens. But in effect, it is the insurers who get to decide where someone should seek treatment.

“It has reached a point where some insurers omit even hospitals from reputed operators from their list,” said Jobilal Vavachan, CEO and vice-president at Aster. “What this means is that they are issuing medical cards that stipulate the insured can only seek the services at their designated facilities.

“In some instances, the omissions are quite offensive to the hospital operators — and only because they would not submit to all the demands by the insurers.”

The bigger names in the health care business can get away with ignoring insurer demands if they see it as being excessive, but not so when an operator owns a one-off clinic or a mid-size hospital. Then, not having enough insurers placing them on their coverage list means the clinic or hospital will not have enough people seeking treatment there.

Mark Adams of The Healthcare Network believes that this is not just an insurer’s issue. “Where you have an oversupplied market, the last thing insurers need are more hospitals or clinics. The key to a system is for insurers to use their volumes to direct more patients to a restricted network in return for reduced prices.

“Opening — and empanelling — more clinics and hospitals dilutes the insurers’ purchasing power and achieves the exact opposite.”

Adams has a point: the last five years did see a significant increase in the UAE’s health care capacity as operators focused on expanding into newer communities in Dubai, Abu Dhabi and elsewhere. But now, it has reached a point where many have started questioning whether too much of capacity was created too soon.

Anil Nair, CEO at Iris Health Services, insists that insurers — and TPAs (third-party administrators) — do not play favourites. “We do not promote any clinic or hospital — what we do is band providers together based on their price point, quality of their doctors and their medical infrastructure.

“We also do not withhold coverage of new entrants to the market. We’ve added 16 new hospitals and clinics to our networks in the last month, from King’s College Hospital Dubai to Releaf Medical Centre in DIP.

“The reality, however, is that consumers take time to accept new names in the market. Realistically, medical service providers cannot expect footfall from the day they are added to a network.

“Another consideration is to determine why providers are being shut out. We have removed providers from our networks based on our due diligence, if we find there has been fraud and abuse.”

Ref: Gulfnews


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