Health Insurance

Throughout the world Health Insurance Organizations share a common and complex challenge.  Namely, how to sustainably control health expenditures while also providing high Quality services for the business domain stakeholders. And this from the one hand This automatically requires the application of policies and mechanisms for the proactive control of the provision of healthcare services, for the implementation of certain administrative measures to reduce fraudulent activity and optimize internal processes and resource management. At the same time, the Quality of Service must be built to embrace such issues as good governance and interoperability, adoption of international standards, streamlining the business processes, providing digital services, substantially facilitating the provision of health care services, etc.

INTRASOFT International, drawing from 20 years of knowledge and experience in developing and delivering Business Systems, meets the demands of this niche market with its creation of Health Insurance and e-Health Suite.  This highly scalable and configurable Integrated Platform supports and automates the business processes within a Health Insurance Organization. The Solution has been designed to electronically support health insurance and health care processes from the ground up. For example, it incorporates services that allow different types of actors (such as medical doctors, hospitals, private clinics, diagnostic centers ad labs, physiotherapists, rehabilitation centers, pharmacies, patients, etc.) to come together and collaborate electronically in a single platform.

Designed using state-of-the-art open architecture technology, the Health Insurance Solution offers the following benefits:

  • Meets the needs of a Health Insurance Organization in the short term
  • Supports statutory requirements (rules, legislation and pricing policy) in a standardized way
  • Supports the Registration of all Health care Actors via various Channels
  • On-line submission and on-line validation and calculation of claims and medical data
  • Quicker clearance of and payment to Health Care Providers
  • Provides Health data Standardization (HL7, ICD, GRD, ATC, GMDN, etc.)
  • Processes Standardization via embedded BPM engine, providing real time active monitoring and performance management
  • Supports Primary Health care (electronic prescription from medical doctors)
  • Abandons manual processes (reduces costs by moving the Insurance Organization to contactless and paperless processes)
  • Manages Health Expenses by applying electronic control mechanisms within the business processes that generate the expenses (e-authorization)
  • Applies Risk Analysis and fraud detection techniques (reduces the risk of paying out on false reimbursement claims)
  • Utilizes digital information and a rich data set to reveal trends and support decision making policy and sustainability of the Organization (Data Analytics and KPI’s)
  • Consolidates a high quality of health data per person (EHR)
  • Enhances digital services and interoperability between systems

The Health Insurance Solution is comprised of the following vertical components:

  • Insured Persons and Employers Registries
  • Health Care Actors Registries
  • Health Products and Services
  • Classifiers and Nomenclatures
  • Health Care Pricing Policies and Contracts
  • Medical Services (e-Prescription)
  • Outpatient e-Health and e-Claims
  • Inpatient e-Health and e-Claims
  • Pre-Authorization Services
  • Contributions Management
  • Claims Clearance and Payments (Reimbursement to Health Care Providers)
  • Health Care Benefits (Reimbursement to Members)
  • EHIR (Electronic Health Insurance Record)

The Solution is supported horizontallyby common modules like:

  • Workflow (Embedded BPM Engine)
  • Business Rules Management and Rules Engine
  • Interoperability Services
  • Financials Integration
  • Data Analytics
  • Risk Analysis and Compliance