Challenges in Claim Cycle Management in Latin America

Steven Shai Gold, Principal, International-Triage Medical Networks (USA) LLC

Steve_ShaiShai began by saying that if the underlying challenge of cross regional claims management is rooted in inter-cultural differences that define the business culture of both payee and provider, then the solution can only be founded upon respect for, and adaption to, the needs of providers whose services are required by insureds. The gap can only be bridged when the economic interests of the provider and the payer are fully aligned. Latin America has some of the best hospitals in the world, Shai pointed out, and they are expensive, but they are worth it. However, inevitably there is a risk that some hospitals will take advantage of the deep pockets of North American insurance companies. Ethics in Latin America are different, and there is recognition that insurers need to be prepared to deal with the above suggestion. The most significant challenges to claims cycle management in Latin America, as identified by Shai in his presentation, include providers being reluctant to bear the risk of post-treatment payment, and providers’ tendency to overcharge foreign payers. One key difference in Latin America compared to the rest of the world is that physician costs often outweigh the cost of the hospital – the opposite of what happens in other regions. Other challenges include a distrust of foreign companies, commitments that are closely linked to personal relationships, different languages and work habits, telecommunication difficulties, insufficient documentation of treatment, and holding the insured hostage to pressure either family members or third party payers for unconditional payment. Shai warned that while use of local networks will not necessarily result in savings off the invoice, it will ensure that you will not be grossly overcharged. Insurers could consider hiring an internist doctor, or team of different specialist physicians in a tourist region, who will work on an insurer’s behalf to ensure fraud is minimized and medical care and costs are examined on the spot. Solutions that payers can use to overcome these challenges can include working via a local network or assistance company, thus avoiding being pegged as a ‘foreign payer’. Insurers should be wary of disagreeing too strongly with a provider, warned Shai, as it can lead to boycotts from other providers in the same market. However, if an insurer does wish to contract directly with a medical provider, then the insurer needs to arm themselves with a lot of respect for the local medical community; they must offer a reasonable contractual framework, and invest in cultivating relationships with key providers. Never offer money to grease the wheels, said Shai, because they will be offended that you believe they are corrupt. Insurers must also be prepared, continued Shai, to have a local guarantee facility, and to honor payment terms. Going into detail, Shai said that contract terms should include language such as: “Pilot phase after which the parties will reconsider the term based on volume and payment within term; claims must include documentation of medical events, all lab tests and diagnostic radiology, inclusive of DVDs containing imaging, medication and dosage, progress towards recovering and discharge with fit-to-fly documentation (with an English translation of the same); and claims may be subject to payer audit.”


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