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Patiently pursuing the goal – the medical device provision process from the policyholders’ point of view

After her traffic accident, Elvira needs a wheelchair for several months so she can look after herself in her flat and run small errands. Elvira has private health insurance. Her children are taking care of her and make a trip to the nearest medical supply store with the prescription. The first thing they are asked when they arrive is whether the costs will be covered by private health insurance.

For the children, this is the beginning of a small odyssey from the medical supply store to the private health insurance company, then back to the medical supply store and finally back to the private health insurance company – a test of patience for Elvira. She is now back from rehab and bristling with motivation. But without a wheelchair, she cannot move!

The medical device provision process in the private health insurance sector

In contrast to statutory health insurance, in private health insurance, making reimbursements for medical devices depends on the policy and the type of medical device. Smaller medical devices, such as bandages, do not require a cost estimate, but are instead reimbursed by the private health insurer as part of the usual settlement procedure if they are included in the policy. For larger medical devices, either reimbursements are made as lump sums from the catalogue or policy-dependent reimbursements are granted. These usually have to be applied for in advance. Depending on the diagnosis, special equipment/models are then also approved. After being approved, reimbursement is made the same way as it is for smaller medical devices. Policyholders obtain the medical device from the medical supply store, pay for it and submit the receipt to their private health insurer. All in all, it is a laborious manual process that takes time.

Elvira is back from rehab

The wheelchair is not available yet. Her health insurer currently has her application for cost coverage. She depends on others to help her at home because she cannot look after herself without a wheelchair. Her daughter is currently on holiday, so for the next five days, everything will all right.

She calls her insurer and is put off. People on holiday, people on sick leave – the backlog for processing claims is huge. She points out the urgency of her situation, but has no choice but to wait.

After another two days, she gets a letter: her insurer has approved the wheelchair. She sends her daughter to the medical supply store. The approved model is currently unavailable there – it will take two to three weeks until it is in stock. The model that is available is much more expensive. Instead of the wheelchair, her daughter brings back a cost estimate for the more expensive model.

Elvira immediately sends it to her insurance company and waits once again. After two days, she calls and asks about it. Her cost estimate has not made its way to the case worker yet. She must continue to be patient. Her daughter can only take care of her for one more day. She calls the insurance company again, and sure enough, the letter has arrived. The claims handler informs her in advance by phone that they will not cover the costs of the expensive model. Elvira is at her wits’ end. What is she supposed to do now? She calls again and is told to go to another medical supply store, but it is on the other side of town. How on earth is she supposed to get there?

After several calls with her insurer and the medical supply store, she arranged for the standard model to be delivered. The next day, the wheelchair is delivered – just in time! Her daughter can go home with peace of mind, and Elvira can look after herself. But the whole process was incredibly nerve-wracking: various phone calls, trips to the medical supply store and to the post office – just like in the old days – and all this in the digital age! She can hardly believe it.

Optimisation potential in the medical device provision process

The electronic prescription of medical devices has already been announced. This announcement must elicit the initiation of a new process in the private health insurance sector, otherwise it will lose any significance it may have had. The insurer’s processes must change to a considerable degree in order to successfully provide their customers with medical devices in a way that is quick and customer-friendly. Let us imagine that correspondence by post had been done away with and that Elvira had been told about a medical supply store right off the bat, including the availability of the wheelchair model she wanted and a possible delivery date. Elvira would have been thrilled!

As of right now, electronic prescriptions are not yet available, so of course an ideal solution cannot be offered in the immediate future. However, things can move along at a significantly faster pace once a prescription is received. Appropriate software is needed to support the claims handler because it is far too complex and time-consuming if they have to do everything manually.

Outlook

The demographic development in Germany continues to show a slight increase in life expectancy and a 22 per cent increase in the number of people who are 67 and older by 2035 (German Federal Statistical Office [Statistisches Bundesamt], 30 September 2021). The baby boomers are becoming pensioners. Unfortunately, high life expectancy is also associated with symptoms of old age that result in the need for care and medical devices. Statistics today already prove this (Barmer Pflegereport [Barmer Care Report] 2 December 2021, 30 per cent increase by 2030). A sharp increase in the number of those in need of care is to be expected when the baby boomers reach this age.

The way I see it, this means that insurance companies have to prepare themselves for the fact that more policyholders will also need more medical devices and the number of requests for them will increase. They either need to provide more personnel for processing these requests or significantly improve the process by means of technical support. Qualified personnel are hard to find. This would indeed help with managing the requests but would not lead to the process being improved. So the only thing left to do is to invest in technical support.

How can adesso help?

adesso is known for IT expertise combined with a high level of specialisation. This results in a wide range of approaches to process optimisation. As is clearly illustrated by the high number of e-initiatives in place, the health insurance industry is under enormous pressure to digitalise their processes. Therefore, we at adesso are intensively engaged in finding possible solutions that offer advantages for everyone involved. We obviously are not medical device specialists, but through our cooperation with HMM* we see good opportunities to make the medical device provision process in the private health insurance industry customer-friendly and efficient. So the ‘crux with the crutch’ should soon be a thing of the past.

Interested? Please feel free to contact me. We will take a look at your processes and work with you to find a forward-looking solution so that you get the electronic prescriptions right on cue and are able to quickly take advantage of all the benefits for a customer-friendly journey. You can find further information on our website.

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*HMM Deutschland GmbH.

HMM Deutschland GmbH is a provider of innovative supply and billing solutions in the healthcare sector. More than 40 health insurance providers are networked with around 30,000 care providers via the ‘central platform’ operated by HMM as well as the ‘LEOS’ online care provider suite (Leistungserbringer-Online-Suite, LEOS) in order to electronically provide policyholders with care, from application to approval, all the way to claims processing and settlement.

Picture Sabine  Fischer

Author Sabine Fischer

Sabine Fischer is a Programme Manager in the Line of Business Insurance at adesso with a focus on digital health offerings for life and health insurance. She has many years of experience in software development and thinks software from the end user's perspective.

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