Contract management at the highest level

In­ter­faces to ex­tern­al or in­tern­al data­bases, ex­tens­ive con­trac­tu­al re­la­tion­ships and multi-layered billing models – for health in­sur­ance funds, con­tract man­age­ment is not pos­sible without a well thought-out system. The stand­ard func­tions of a con­tract man­age­ment solu­tion map basic pro­cesses. For health in­sur­ance funds, the soft­ware must be adapted and ex­pan­ded. With their ex­pert­ise and ex­tens­ive ex­per­i­ence from pre­vi­ous pro­jects, otris con­sult­ants are ideally placed to support health in­sur­ance com­pan­ies with en­ter­prise-wide digital con­tract man­age­ment.

Example of se­lect­ive con­tracts

Health in­sur­ance com­pan­ies are obliged to provide a legally defined scope of ser­vices. These ser­vices are anchored in col­lect­ive con­tracts that health in­sur­ance funds con­clude with the As­so­ci­ation of Stat­utory Health In­sur­ance Phys­i­cians, for example. Ser­vices that health in­sur­ance funds offer their members in ad­di­tion to this are handled through se­lect­ive con­tracts. The special feature: the health in­sur­ance fund con­cludes se­lect­ive con­tracts dir­ectly with the service pro­viders (e.g. spe­cial­ists, hos­pit­als, medical care centres) and not with the As­so­ci­ation of Stat­utory Health In­sur­ance Phys­i­cians. As a result, health in­sur­ance funds have to manage se­lect­ive con­tracts that contain thou­sands of dif­fer­ent con­tract par­ti­cipants per in­di­vidu­al con­tract. This creates the chal­lenge of as­sign­ing a large number of data records to a con­tract within the system and keeping these dynamic data records up-to-date. In ad­di­tion, se­lect­ive con­tracts contain one or more ICD as­sign­ment(s) to link a disease class (ICD = In­ter­na­tion­al Stat­ist­ic­al Clas­si­fic­a­tion of Dis­eases and Related Health Prob­lems). In summary: Com­pared to usual con­tracts with two con­trac­tu­al part­ners and without dynamic content, the effort in­volved in a se­lect­ive con­tract is con­sid­er­able.

Man­aging data with in­ter­faces

Man­aging the entire stock of se­lect­ive con­tracts of a health in­sur­ance fund is thus only pos­sible via complex data man­age­ment and in­ter­faces to ex­ist­ing data­bases. For the data­base con­nec­tion (e.g. to the Bit­mar­ck ICD data­base), the otris experts rely on proven, self-de­veloped in­ter­faces. Via the con­nec­tions, not only is the se­lec­ted data linked to the con­tract, but it is also com­pared and checked for up-to-date­ness. The system auto­mat­ic­ally syn­chron­ises changes in the con­tract par­ti­cipants (e.g. due to prac­tice dis­con­tinu­ation or service changes). At the same time, it remains pos­sible to change data records manu­ally.

Complex con­tracts, com­plic­ated billing

The complex con­tracts in­ev­it­ably require equally complex billing. otris con­tract also sup­ports health in­sur­ance com­pan­ies in this busi­ness-crit­ic­al cor­por­ate process: in order to check the leg­al­ity of sub­mit­ted bills, the system exports the con­tract data in order to sub­sequently enable auto­mated re­con­cili­ation. After the export, the data is avail­able for a check that com­bines the speed of auto­ma­tion with the special case check of the clerks.

Sim­pli­fy through di­git­al­isa­tion

The complex ad­min­is­trat­ive struc­ture of the se­lect­ive con­tracts shows only a small section of the con­tract man­age­ment of a health in­sur­ance fund. Rehab frame­work con­tracts with their vari­able scopes of be­ne­fits, drug dis­count con­tracts or con­tracts for GP-centred care (HzV) are other areas that require com­pre­hens­ive data man­age­ment. The over­rid­ing in­ten­tion behind every process in the con­tract man­age­ment of a health in­sur­ance company can be sum­mar­ised simply: The insured person should receive the benefit to which he or she is en­titled quickly and with little ad­min­is­trat­ive effort. This only works if health in­sur­ance com­pan­ies enter into direct contact with their poli­cy­hold­ers and advise them ac­cord­ing to their needs. Here too, otris soft­ware provides support with in­di­vidu­al solu­tions.

On request: with geo-in­form­a­tion system

The otris con­sult­ants develop in­ter­faces to systems that health in­sur­ance fund em­ploy­ees use in cus­tom­er con­sult­ing. A proven ex­ten­sion of the con­tract man­age­ment soft­ware otris con­tract links con­tract data with geoin­form­a­tion. In this way, the system de­liv­ers results in re­sponse to queries that health in­sur­ance em­ploy­ees need for tar­geted coun­selling ses­sions. For example: the address of the nearest doctor who provides a certain se­lect­ive service. Or a list of all doctors within a radius of 50 kilo­metres who provide a certain se­lect­ive service.

Reduce com­plex­ity

Health in­sur­ance funds aim to provide their members with in­di­vidu­al­ised care and ser­vices tailored to their needs. At the same time, more in­di­vidu­al­ity means more com­plex­ity in the con­trac­tu­al re­la­tion­ships that form the basis of service re­mu­ner­a­tion. otris soft­ware sup­ports health in­sur­ance com­pan­ies with cus­tom­ised, digital solu­tions that sim­pli­fy com­plex­ity. By struc­tur­ing, in­ter­fa­cing and auto­mat­ing con­tract man­age­ment, health in­surers save re­sources that are used to im­ple­ment the primary task: To provide each member with suf­fi­cient, ap­pro­pri­ate and eco­nom­ic­al care when needed.