Health care providers and insurer relationship causing heartburn
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DUBAI: Building a new hospital or clinic in the UAE is the easy part these days. But ensuring insurers will include them in the coverage is the tricky part.

This is how it works: In their group policy agreements with employers, insurers clearly stipulate that those insured can only seek consultation or treatment at pre-approved hospitals or clinics. So, for a new health care facility, it is important that it is on that pre-approved list to have enough people coming to it. And it needs to be on the list as soon as it opens. But in effect, it is the insurers who get to decide where someone should seek treatment.

“It has reached a point where some insurers omit even hospitals from reputed operators from their list,” said Jobilal Vavachan, CEO and vice-president at Aster. “What this means is that they are issuing medical cards that stipulate the insured can only seek the services at their designated facilities.

“In some instances, the omissions are quite offensive to the hospital operators — and only because they would not submit to all the demands by the insurers.”

The bigger names in the health care business can get away with ignoring insurer demands if they see it as being excessive, but not so when an operator owns a one-off clinic or a mid-size hospital. Then, not having enough insurers placing them on their coverage list means the clinic or hospital will not have enough people seeking treatment there.

Mark Adams of The Healthcare Network believes that this is not just an insurer’s issue. “Where you have an oversupplied market, the last thing insurers need are more hospitals or clinics. The key to a system is for insurers to use their volumes to direct more patients to a restricted network in return for reduced prices.

“Opening — and empanelling — more clinics and hospitals dilutes the insurers’ purchasing power and achieves the exact opposite.”

Adams has a point: the last five years did see a significant increase in the UAE’s health care capacity as operators focused on expanding into newer communities in Dubai, Abu Dhabi and elsewhere. But now, it has reached a point where many have started questioning whether too much of capacity was created too soon.

Anil Nair, CEO at Iris Health Services, insists that insurers — and TPAs (third-party administrators) — do not play favourites. “We do not promote any clinic or hospital — what we do is band providers together based on their price point, quality of their doctors and their medical infrastructure.

“We also do not withhold coverage of new entrants to the market. We’ve added 16 new hospitals and clinics to our networks in the last month, from King’s College Hospital Dubai to Releaf Medical Centre in DIP.

“The reality, however, is that consumers take time to accept new names in the market. Realistically, medical service providers cannot expect footfall from the day they are added to a network.

“Another consideration is to determine why providers are being shut out. We have removed providers from our networks based on our due diligence, if we find there has been fraud and abuse.”