CMA Issues Health Insurance Claims Revenue Cycle Management Regulation

Al Maamari, Licensed companies will reduce differences and disputes between insurance companies and private health institutions

The Capital Market Authority has issued a regulation for the activity of managing the health insurance claims revenue cycle by Decision No. (107/ 2022), which is aims to  organize the documentary cycle and providing the service of filing, following up and processing of  insurance claims on behalf of the health service provider. The regulation includes the necessary rules to license health insurance claims revenue cycle management companies in the Sultanate of Oman.

On the importance of the regulation, Ahmed  Ali AlMaamari, Vice President for Insurance Sector, Capital Market Authority, confirmed that the issuance of the regulation governing the activity of managing health insurance claims revenue cycle comes in light of the ongoing preparations for the implementation of the compulsory health insurance  scheme for the employees of the private sector and visitors to the Sultanate of Oman, hence, the   legislative requirements related to the parties of the health insurance process are ready and complete.

Al Maamari added that the remarkable growth of the health insurance activity in the local market, the increase in the number of health insurance policyholders and the regulatory procedures associated with the health insurance structure requires to introduce such activity and provide a clear regulation that ensure an appropriate investment environment, which contributes to the safety, accuracy and high quality of the transactions related to health insurance services.

Al Maamari added, "This activity will also contribute to improving the quality of health insurance claims sent to insurance companies, verifying their compatibility with the medical coding system, reducing differences and disputes between insurance companies and private health institutions as a result of rejected claims and nonpayment. He said that the introduction of this type of activities in the insurance market will contribute to expanding the role of the insurance sector to accommodate the graduate of educational institutions, as well as providing technical and administrative job opportunities, whether in the disciplines related to health sciences or accounting, finance and administration and information systems.

According to the regulation, the activity will provide many services to private health institutions, related to managing the documentary cycle, providing medical coding services, billing, revenue development, technical, financial and advisory services, as the company will be concerned with verifying  the identity of the insured and eligibility for treatment services further to transferring treatment services to billable fees, processing rejected claims, knowing the source of the problems of rejected claims and working to correct them, in addition to sending health insurance claims electronically to insurance companies or health insurance claims administrators, and ensuring that they receive those claims according to the specified timeframes.

The company will also be responsible for following up the collection of funds for

treatment services provided to health insurance policyholders, as well as training and qualifying the employees of private health institutions to use the approved medical coding systems or the systems that may be introduced in the future.

The importance of  private health institutions  contracting with health insurance claims revenue cycle management companies is to raise the quality of health insurance claims that will be sent to insurance companies or health insurance claims administrators , reduce administrative and operational costs for private health institutions, and reduce health insurance claims rejected by Insurance companies or health insurance claims administrators , in addition to improving and simplifying the operational procedures of private health institutions, and ensuring the financial stability of the private health institution.

It is worth to note that the audited financial statements of the insurance sector for the year 2021 indicated an increase in health insurance premiums by 5.6% to RO 164 million, and the value of compensation related to health insurance activity decreased by 0.5% to RO 120 million. The data also showed an increase in the health insurance policies by 88% to 23,000 policies.