HSE seeks ‘resolution support’ for health insurance claims

The HSE is seeking support in resolving private health insurance claims within the statutory and voluntary hospital sector.

In a recent tender announcement, the Executive stated it was looking to establish a “single supplier framework” to aid in the resolution of private health insurance claims within 48 public hospitals.

The HSE said it expected the supplier to attend on-site at hospital locations, at the request of local hospital management, to review specified private health insurance claims.

A HSE spokesperson told the Medical Independent (MI) that the proposed contract aimed to “assist hospitals in resolving health insurance claims where said claims are either underpaid/unpaid due to outstanding queries of a complex medical nature from an insurer”.

“This contract does not impact on the private insurance claim submission process at a hospital level,” the spokesperson added. 

The tender document outlines that each hospital will review their outstanding claims list and select claims for review by the service provider.

“There may be a wide variety of reasons as to why claims may be part paid or even remain unpaid,” the document stated.

Hospitals will retrieve medical files for review. The HSE stated that patient files cannot be removed from hospital sites.

The provider will “recommend amendments, or recommend seeking further details in order to assist with the resubmission of the claim to the relevant health insurer, which will result in payment of the claim”, according to the tender.

The process may result in certain claims not being pursued for payment by the hospital, the HSE added.

“HSE Finance Shared Services and HSE National Finance will also require engagement with the service provider on an ad hoc basis to assist and/or augment the claims submission process. The claims process with all public hospitals is currently managed through a system called Claimsure.”

It is understood that there are significant backlogs and delays within public hospitals in resolving private insurance claims.

However, the HSE spokesperson did not comment on the matter when questioned by MI. They said further details on “value and volumes” would be provided at the next stage of the tender process.

The deadline for receipt of submissions is 11 May.