The company does this through insurance and TPA programs that do the following:
• Reducing or removing the administrative burden on senior management bodies in determining eligibility and priority of those receiving medical services.
• Providing medical reports for each Subscribe with the financial cost for him, and providing a permanent central file for each patient.
• The use of modern technologies in managing medical expenses according to the various contractual terms, and preventing any violations so that claims are examined before they occur to be subjected to the terms of the contract and making decisions automatically using the appropriate communication mechanism:
o Availability of limits or ceilings for benefits (wages – recipes – services) to create self-censorship.
o Agreement with service providers on specific costs for procedures, medicines, supplies, and others.
Regulating the treatment mechanism inside and outside the hospitals:
• Matching the procedure with the physician’s specialization, and matching the procedure with another procedure, and observing the period from one procedure to another (repeating the procedures).
• Matching the procedure with the diagnosis, then matching them all with the dispensed medicine while observing the amount of procedures with the status of the disease.
• Conformity of medical procedure with age and gender.
• Monitor the doctor’s right to perform, check, or dispense a specific drug.
• Monitor the average days of stay and the average cost per case.
• The company has the right to see the patient’s file.
• Apply a mechanism that leads service providers to bear any increases in treatments
Regulating the medicine dispensing mechanism:
• Monitor the compatibility of the drug with sex and age.
• Monitoring the periods between drugs (repeated dispensing of drugs).
• Monitor the compatibility of the drug with other drugs.
• Monitor the prices and quantities of prescribed medications.
• Determining the price, the insurance company incurs for each drug scientific name.