Hospitals struggling to get insurer support? B

Experts discuss the ‘tricky’ issue of coverage

uilding a new hospital or clinic in the UAE is the easy part these days. But ensuring insurers will include it 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.

Ignoring demands

“It has reached a point where some insurers omit even hospitals from reputed operators from their list,” said Jobilal Vavachan, CEO and vicepresident 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.”

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. 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.”

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.”