The Central Insurance company of Iran, the industry’s regulatory body, has called on insurance companies to accelerate the payment of medical insurance claims to hospitals, medical centers and drugstores.
As per the report published by Aiin News, payouts to medical centers and drugstores must be settled within approximately 15 working days of the submission of documents.
According to Majid Behzadpour, the CII chief, insurers’ delay in the settlement of dues of medical centers and drugstores has disturbed the supply chain of medicine in the country and contributed to a shortage of medicine and a rise in prices.
“In order to prevent these problems, insurance companies must take necessary measures to make sure that claims related to hospitals and pharmacies are paid soon after the submission of documents,” he added.
The CII’s deputy for supervision has also been tasked to oversee insurance companies’ performance in this regard, by publishing monthly reports and taking suitable measures in case insurance companies fail to comply with the rules.
Latest data published by CII indicate that medical insurance was the second top source of income for insurance companies in the last fiscal year (March 2022-23), with a 26.16% share of the total.
The total value of claims paid by insurers during the period was 1,000 trillion rials ($1.83 billion), with the medical segment topping the list with 35.72%.
A large part of the claims was to cover bills related to the Covid-19 pandemic. Soon after the disease struck, insurance companies were told to cover all the expenses of policyholders who contracted the virus and expand their scope to include PCR tests.
Despite the devastating impact of the disease, insurers saw the pandemic as a rare opportunity to improve their credentials with customers who rightly complain about their strange practices, mainly in private hospitals that demand full payment of bills and refuse to deal with the bloated bureaucracy of insurance companies.
More than 25 million Iranians have medical insurance, which also accounted for the highest portion of claims during the period. CII figures show that from a total of 69 .3 million claims, 94.7% or 64 million were for medical insurance.
In recent months, there have been consistent complaints in the local media about shortages and the rising prices of medicine. The focus has been mainly on importing medicine for rare and special diseases that have become unaffordable for large sections of the society.
Insurers’ Concerns
The increasing number of fraudulent medical claims poses a big challenge for insurers, though experts say electronic prescriptions plus data sharing platform can help tackle the problem.
Majid Garshasbi, an insurance expert, said the number of fraudulent medical claims is on the rise, along with fake prescriptions.
"Fraud cases in the medical category now outnumber those of third-party auto insurance. It is believed that fraudulent cases account for 15% of the total cases in Iran, but electronic prescriptions could help reduce this considerably," he said.
The expert noted that the lack of a central data collection platform has led to this unacceptable state of affairs.
"Insurance companies need to start sharing policyholder data … Analyzing data can go a long way in curbing healthcare fraud,” he said.
Referring to unhealthy competition in the medical insurance sector, Garshasbi said, "As per the law, insurance companies should settle medical insurance claims within 15 days. Some companies publicize that they can settle claims in five days but in practice fail to do so."
By failing to meet their declared commitments, insurance firms harm the key sector because if this pattern continues, the people and hospitals will no longer trust insurers.
Mojtaba Atri, a board member of Dana Insurance Company, believes that insurance companies need to develop a shared interest in supervising operations in the key segment.
"Insurance companies can share records and create a list of fraudulent policyholders to suspend services to them. The Ministry of Health and the Central Insurance Company of Iran also need to further promote the electronic prescription system,” he said.
Electronic prescription is the computer-based electronic generation, transmission and filling of medical prescriptions, by replacing paper and faxed prescriptions.
E-prescriptions allow a physician, physician’s assistant, pharmacist, or nurse to use digital prescription software to electronically transmit a new prescription or renew authorization to a community or mail-order pharmacy.
