What is a guided approach?
Guided hospitals are a relatively new option. In recent years, insurers have worked hard to develop a claims function whereby they guide members to certain facilities and specialists based on the clinical requirements of that specific claim.
Why?
Insurers want members to receive treatment, quickly, efficiently and in the most cost-effective manner. They use the data they have collected of years and years of paying claims, to model pathways that guide members to the right care.
Most insurers will try to give the member two or three choices for specialists and/or hospitals following their analysis of the claim request.
One of the most frequent questions – Are insurers just going to guide us to the cheapest route?
Cost will always form part of the equation, but there are other factors that determine their results. Each insurer has their own process, but they will likely all consider the following.
· Location
· Diagnosis
· Complexity
· Availability
· Pre & Post Operation Pathways
Guided pathways have been mainly available on Corporate plans but following their success, we have seen a development to include Private/Individual and SME plans in recent years.
There are long-term advantages associated with guided hospital plans, they reduce unnecessary consultations, diagnostic tests & therapy sessions. This has a long-term impact on claims spend and overall premium, but it also eases the short-term burden for members as they are not attending unnecessary appointments.
Ultimately, all insurers are working to make their plans affordable in a difficult economic climate. More employees are requesting health insurance and individuals are purchasing their own private health insurance, so insurers are doing what they can to develop ways to reduce unnecessary costs and control claims spend without jeopardising the care for their insured members. The guided option can offer a premium saving of approximately 20% on average. Guided pathways are becoming more and more common, especially with the uninsured population who appreciate the insurers doing the work for them. In some ways, the insurers are offering a concierge service and a premium saving all in one option.
How do I choose the right hospital list?
This is where a reputable broker can help. It isn’t a case of choosing the insurer then picking the hospital list. You need a broker to understand the demographics of your workforce that can structure and match the hospital lists to your workforce then see which is the best route for you.
We understand that medical insurance benefits and options have so many variables. We want to offer our thoughts on one ‘option’ within all insurance contracts, Hospital Lists.
Don’t confuse Hospital Groups such as BMI, Nuffield, Spire, HCA, Circle Health, with Insurer Hospital Lists.
Each insurer designs their proposition to include specific groups of hospitals within defined lists which you can choose to include within your plan.
Let’s look at the hospital options, on SME propositions for the top 4 insurers based on market share in the UK.
Aviva
Key (Core List) – Covers most of their recognised facilities through the UK, Channel Islands & Isle of Man. They have a select handful of facilities that are not included – which at the time of writing this blog includes: Harley Street, Lister, London Bridge, Portland plus a few others.
Extended – For an increased premium, you can choose to include those not covered on Aviva’s Key list, therefore extending you cover to include every Aviva recognised private facility in the UK, Isle of Man & Channel Islands.
Signature – Aviva will offer discounted rates if you choose to restrict access to hospitals to recognised facilities in just Northern Ireland & Scotland.
Trust – Aviva will offer discounted rates if you choose to restrict access and ask individuals to use only private patient units of NHS trust and partnership hospitals.
Expert Select – Aviva’s guided approach to claims (further comments to follow).
AXA
Directory (core list) – A simple and very effective approach with AXA’s core cover. Their standard hospital list offers cover at every AXA recognised facility in the UK, Channel Islands & Isle of Man.
Guided Option – AXA’s guided approach to claims (further comments to follow).
Business Protect – A reduced list that sits alongside a new AXA product designed to grow the market by offering a lower cost product to uninsured businesses.
Bupa
Participating – Access to every Bupa recognised facility in the UK, Channel Island & Isle of Man.
Partnership – A specifically designed network to help companies reduce costs but still have access to a wide range of hospitals, usually within hospital groups such as BMI, Nuffield, Spire, HCA & Circle Health. This doesn’t mean that all those facilities in the groups are covered.
Guided Care – Bupa’s guided approach to claims (further comments to follow).
Vitality
Countrywide (core list) – Covers most of their recognised facilities through the UK, Channel Islands & Isle of Man, similarly to Aviva there are a handful of facilities that are not included, these are mainly positioned in central London.
London Care – For an increase in premium, Vitality will extend cover to all of their recognised UK, Channel Islands & Isle of Man facilities.
Local – Now closed to new business, Vitality previously had an option to restrict access to facilities in a specific local area.
Consultant Select – Vitality’s guided approach to claims (further comments to follow).