What is Health Insurance?
Health Insurance companies, also sometimes referred to as "healthcare payers," handle the delivery of health insurance plan benefits to customers (e.g., policy holders), address any related customer issues and manage networks of healthcare providers (e.g., physicians, hopitals, etc.). Health insurance can be provided on an individual or group (company or family coverage) basis. Services provided by health insurance companies to their plan members include healthcare provider identification and selection, claims processing, healthy living education and online account management, among other various forms of health-related assistance. Health insurance companies are also responsible for maintaining relationships with network healthcare providers (physicians, clinics, hospitals, etc.) to ensure continued coverage.
Health Insurance Benchmarking ReportBenchmarking Report Bundle
Benefit Accuracy RateBenchmarking Report
Health Insurance KPI EncyclopediaKPI Encyclopedia
Health Insurance Best Practices GuideBest Practices Guide
Health Insurance Organization Chart TemplateOrg Chart Template
Health Insurance Customer ServiceWorkflow Template
Benefit Accuracy Rate
The number of patient responsibilities for health insurance claims in which the payer returned the correct patient responsibility information (based on patient benefits eligibility) at the t...
KPI Type : Quality
Formula : (Number of Instances where Correct Patient Responsibility Amount was Communicated by Payer / Total Number of Patient Responsibility Amounts Communicated) * 100
KPI Benchmark Range : 66.1%-98.5%
Claims Auto-Adjudication Rate
The total number of claims that are automatically adjudicated (i.e., those approved or denied automatically without need for manual intervention) divided by the total number of claims adjudi...
KPI Type : Quality
Formula : (Number of Claims Auto-Adjudicated / Total Number of Claims Adjudicated) * 100
KPI Benchmark Range : 36.5%-83.6%
A typical health insurance company is composed of several common sub-functions, or teams, that work together to attract new members, provide quality service to existing policyholders, process and pay claims and develop relationships with health care providers. Browse our Health Insurance organization chart page to learn about the roles and responsibilities of each major function. Then, download our org chart template (PDF, Visio, PPT) to plan and support health insurance operations improvement efforts.
Check out our health insurance best practices page to view selected descriptions of work methods that have been proven to produce better results (as compared to other, similar methods). Want more? Download our Health Insurance best practices guide, which provides a healthy selection of valuable best practices that can be incorporated to improve health insurance operations. There might not be only one "best" way to perform every task. However, there is always a "better" way.