Healthcare Payer Solutions (EMEA)

Healthcare Payer Solutions (EMEA)

Chris IbellVP Oracle Consulting for Healthcare – Europe, Middle-East and Africa

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The following is intended to outline our general product direction. It is intended for information purposes only, and may not be incorporated into any contract. It is not a commitment to deliver any material, code, or functionality, and should not be relied upon in making purchasing decision. The development, release, and timing of any features or functionality described for Oracle’s products remains at the sole discretion of Oracle.

Safe Harbor Statement

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• Leadership in Healthcare

• Innovation in Healthcare Solutions

• Results Achieved by Oracle Customers

Agenda

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Did You Know?Oracle inHealthcare

More than 300 leading healthcare providers run Oracle Applications - Oracle

20 of the Top 20 US Health Insurers run Oracle Applications - S&P

10 of the top 12 Fortune Global 500 healthcare organizations run Oracle Apps

More than 80 Healthcare Payers run Oracle applications - Oracle

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The Challenges We’re Hearing

Reduce Healthcare Reduce Healthcare and Operating and Operating

CostsCosts

“How can I satisfy the big number of ever changing regulatory requirements in my country?”

Governments issuing Healthcare reform bills (structural changes)Governments issuing Healthcare reform bills (structural changes), introducing privatization, , introducing privatization, reducing/changing the coverage of public health plansreducing/changing the coverage of public health plans

Comply with Comply with Changing Changing

RegulationsRegulations

“How can I effectively use healthcare management /procurement? How can I have a benchmark cost for my operations?”

Retain and Retain and Grow Grow

MembershipMembership

“How can I grow by retaining my members and winning new ones? How can I satisfy today’s empowered consumers through (self-)service?”

Mergers and acquisitions are happening in various European countMergers and acquisitions are happening in various European countries, payer ries, payer organizations are becoming larger and larger and are struggling organizations are becoming larger and larger and are struggling with consolidationwith consolidation

Healthcare costs are unsustainably growing, driven by fundamentaHealthcare costs are unsustainably growing, driven by fundamental factors, e.g. aging population l factors, e.g. aging population and medical innovationand medical innovation

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Agenda

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Oracle Healthcare Payer Solutions

Retain and Grow

Health Plan

Membership

• Oracle Self-service Insurance, Oracle OpenBeleid and Customer Service Center

• Oracle Self-service Insurance, Oracle OpenZorg

Comply with Changing

Regulations


Regulations

• Oracle OpenZorg - Health Plan Definition and Healthcare Management

• Oracle OpenBeleid and Oracle Discoverer (or 3rd party reporting tool)

• Oracle OpenZorg, Oracle Financials

• Oracle OpenZorg Healthcare Procurement and Oracle OpenBeleid

• Oracle OpenZorg Claims Processing

• Oracle OpenZorg, Oracle OpenBeleid, Oracle Self-service Insurance and Customer Service Center

Reduce Healthcare and

Operating Costs

Reduce Healthcare and

Operating Costs

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Retain and Grow

Health Plan

Membership

• Oracle Self-service Insurance, Oracle OpenBeleid and Customer Service Center

• Oracle Self-service Insurance and Oracle OpenZorg

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Retain and Grow MembershipRequirement

Retain individual and group membership

Oracle Capability

Customer Service CenterOracle Self-service Insurance

The Oracle Difference

Only payer-specific self service and off-the-shelf member intelligence for all channels

Consolidate systems as a result of mergers and acquisitions

Oracle OpenZorg and Oracle OpenBeleid

Only comprehensive off-the-shelf solution in Europe

Support recruitment and enrollment of new membership

Siebel Marketing, Oracle Self-service Insurance and OracleOpenZorg

Only payer-specific solution for recruitment and enrollment of new members

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Oracle Self-service Insurance

Provides customers with an easy to use self service application

Use of web and email channel for maximum convenience Ability to review and modify insurance policies at any timeAbility to review instant quotes and sign up onlineProvides lower costs for the insurerBetter quality

Provides customers with an easy to use self service application

Use of web and email channel for maximum convenience Ability to review and modify insurance policies at any timeAbility to review instant quotes and sign up onlineProvides lower costs for the insurerBetter quality

Retain and Grow Health PlanMembership

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Oracle Self-service InsuranceComponents

Database

ApplicationServerOracle technology

DefTool™ Composer™eBilling Manager

Siebel edocs

Web application

Oracle Selfservice Insurance

Custom made solutions


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Oracle Self-service Insurance“Open” part

• Receive an instant quote• For individual insurances as well as for collective agreements• Confirmation email

• Sign-up online• For individual insurances as well as for collective agreements• Approval by groupadministrator in case of collective agreement

(configurable)• Confirmation email

• Login• Enrollment new user• Log in• Forgotten password


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Oracle Self-service Insurance“Closed”part - dashboard

• Dashboard policy owner• Profile => modify profile data• Overview policies => view policy details, modify policy• Raise service requests• Overview of statements => view statement details• Own Risk usage

• Dashboard Contractor• Profile• Service requests for validation• Overview of collective agreements and policies within agreement• Overview of statements => view statement details


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Retain and Grow Profitable Health PlanMembership

The Member-Centric ApproachCRM

PoliciesClaimsService

RequestsInteractions

Web & Email

Contact Centre

MemberInformation

MemberInformation

Back Office

Single secure repository of member interaction historyMulti-channel accessUnified platform for new “customer focused” services

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Regulations


Regulations

• Oracle OpenZorg - Health Plan Definition and Healthcare Management

• Oracle OpenBeleid and Oracle Discoverer (or 3rd party reporting tool)

• Oracle OpenZorg, Oracle Financials

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Comply with Changing Regulations

Requirement Oracle Capability The Oracle Difference

Deliver adaptive and flexible back-office process support

Oracle OpenZorg - Health Plan Definition and Healthcare Management/Procurement

Only Oracle OpenZorgsupports user-defined and changing business rules, for both public, private and mixed environments

Support changing accounting needs

Oracle OpenZorg, Oracle Financials

Only payer solution where integration with the general ledger is supported via user-defined translation rules

Support mandatory reporting requirements

Oracle OpenBeleid and Oracle Discoverer (or 3rd

party reporting tool)

Only Oracle OpenBeleidoffers off-the-shelf star schema’s for claims and member data combined

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Oracle OpenZorg Payer Solution: Key Components•Policy Management – supports the entire process from enrollment to premium calculation, automatically producing customer documentation such as policy statements and healthcare entitlement cards, as well as invoices and financial transactions. Retroactive policy changes are supported with automatic premium recalculation.

•Claims Processing – provides an integrated claims solution where claims from policy holders or healthcare providers are automatically adjudicated based on configurable business rules, leading to straight-through processing and payment. Claims can be processed online or in batch and can be corrected automatically. Bi-directional exchange of claims information with healthcare providers is supported.

•Health Plan Definition – allows for the definition of an unlimited number of health insurance products for individually insured persons and collective contracts. Health plans defined by law and legislation can be created, and changes can be handled by adapting product definitions. Policy Management and Claims Processing can immediately use all new and modified product definitions.

•Healthcare Procurement – supports all levels of agreements with healthcare providers, ranging from professional group level to individual contracting. Agreements can be specified down to treatment level (also at DRG level). Claims Processing will directly check all types of agreements. The flexibility in Product Definition and Healthcare Procurement enables client-specific rule definitions to be entered without any programming effort.

Comply with Changing RegulationsOracle OpenZorg

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Oracle OpenBeleid: Understanding Your Business

•Solution for reporting and analysis• mandatory (external) reporting • claims analysis for cost control• provider comparisons for benchmarking• product/health plan profitability, also premium calculation input• member analytics• influx, outflux• financial reporting

•Directly suitable for end users (no IT staff needed)•Separate Data Warehouse with Discoverer query tool

• end user layer included

•Solution for reporting and analysis• mandatory (external) reporting • claims analysis for cost control• provider comparisons for benchmarking• product/health plan profitability, also premium calculation input• member analytics• influx, outflux• financial reporting

•Directly suitable for end users (no IT staff needed)•Separate Data Warehouse with Discoverer query tool

• end user layer included


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OpenBeleid Star Schemas (Datasets)

• Claims/Declined claims• Premiums• Insured persons• Financial flow• Influx – Outflux• Medical Authorizations


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US GAAPUS GAAPUS GAAPFrench FiscalFrench FiscalFrench Fiscal

Flexible Accounting Solution

Payables InvoicePayables InvoicePayables Invoice

Centralized AccountingCentralized Centralized AccountingAccounting

DrDr CrCr

• Flexible Chart of Accounts

• User-editable accounting rules

• Translation rules from Oracle OpenZorg

• Multiple accounting and currency representations

• Subledger daybooks (journals)• Flexible reporting and inquiries

Description


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Reduce Healthcare

And Operating Costs

Reduce Healthcare

And Operating Costs

• Oracle OpenZorg Healthcare Procurement and Oracle OpenBeleid

• Oracle OpenZorg Claims Processing

• Oracle OpenZorg, Oracle OpenBeleid, Oracle Self-service Insurance and Siebel Call Center

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Reduce Healthcare and Operating CostsRequirement Oracle Capability The Oracle Difference

Drive effective care purchasing through advanced analytics

Oracle OpenZorg Healthcare Procurement and Oracle OpenBeleid

Most advanced functionality for managing agreements and supporting negotiations with all healthcare providers

Streamline operations, minimize manual processes, reduce errors and paper output

Oracle Self-service Insurance and Customer Service Center

Only integrated off-the-shelf modular solution from front to back office with analytics

Optimize claims auto-adjudication in compliance with the health plan rules and provider agreements

Oracle OpenZorg Claims Processing

Only fully automated claims adjudication engine checking all health plan definitions and provider agreements

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Oracle OpenZorg Comprehensive Back Office Solution for Healthcare Payers

Both public and privateCovers all primary processes and many supporting processesMulti-organization and multi-brand supportBoth direct and intermediary channelsBoth individual and collective marketFlexible products- and healthcare procurement engine

Reusable data components -> efficient maintenanceConnective, Robust and ScalableSeparate, but fully integrated Data Warehouse (Oracle OpenBeleid)Separate, but fully integrated Self-service solution (OSI)

Both public and privateCovers all primary processes and many supporting processesMulti-organization and multi-brand supportBoth direct and intermediary channelsBoth individual and collective marketFlexible products- and healthcare procurement engine

Reusable data components -> efficient maintenanceConnective, Robust and ScalableSeparate, but fully integrated Data Warehouse (Oracle OpenBeleid)Separate, but fully integrated Self-service solution (OSI)

Reduce Healthcare and Operating Costs

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Oracle Support for Healthcare is Complete

• Healthcare applications capabilities• Database technology to support small to large and

multiple healthcare organizations• Access, Identity management and security that is world

reknown • Only complete standards-based, semantically

interoperable Health Information Exchange (HIE)• Most out-of-the-box self-service transactions (100s) to

reduce HR costs• Only integrated contracting, procurement, and payment

for materials and contingent nursing staff solution• #1 enterprise software vendor

• ERP, CRM, HCM and more• Most scalable, reliable, secure infrastructure• Most complete range of on-demand and on-premise

deployment options• Largest development, consulting and support team

• 29,000+ across 145+ countriesOperating System

Database

FusionMiddleware

Tools / J2EE

Applications/Business

Intelligence

Consulting

HTB

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Summary

• Retain and grow health plan membership• Comply with changing regulations• Reduces healthcare and operating costs

Oracle Self-service InsuranceSiebel CRMOracle OpenZorgOracle OpenBeleidOracle FinancialsOracle Technology platform


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Agenda

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Delta Lloyd Group Consolidates Back-Office using Oracle Payer Solutions

CUSTOMER PERSPECTIVE“Oracle enables the combination of forces in the market. In the turbulent healthcare market with many changes in law and legislation, costs are an important issue. Therefore re-inventing the wheel is undesirable. With Oracle we work with state-of-the-art technology and with people who are solution-oriented and available when needed.”- Ingrid Visscher, chairman of the board of Delta Lloyd Healthcare.

COMPANY OVERVIEWDelta Lloyd Group is a banking and insurance group employing approximately 6,500 staff (in FTEs). The Group consists of eight divisions active in four countries, with the following core activities: Delta Lloyd Insurance; insurance and pension services via independent intermediaries in the Netherlands OHRA Insurance; insurance and pension services sold direct to personal and business customers in the Netherlands ABN AMRO Insurance; insurance and pension services via the distribution network af ABN AMRO Bank in the Netherlands Delta Lloyd Asset Management; Delta Lloyd Banking; Delta Lloyd Property; Delta Lloyd Germany; Delta Lloyd Life Belgium

CHALLENGES OPPORTUNITIES•Pursued consolidation of back office systems to achieve cost reductions (uniform processes, one application, system)

SOLUTIONSOracle OpenZorgOracle Database 10g, Oracle Fusion Middleware 10gCurrent implementation:The last part of Ohra insured persons are migrated to Oracle OpenZorgleading to an implementation with all 800.000 insured persons

RESULTS• Multi brand, multi organization

implementation• Consolidated back-office across different

organisational units and implemented standard processes

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Azivo Implements Efficient Back-Office Payer Solutions

CUSTOMER PERSPECTIVE“With a multi-year contract for OracleOpenZorg, Azivo created certainty for a stable and efficient execution of its Healthcare Insurance back-office. To us OpenZorgmeans a flexible and customisable back-office.”Aad de Groot, General Manager

COMPANY OVERVIEWAzivo is a regional mutuality with 150.000 insured persons. It’s customer base is a combination of public (largest part) and private.

CHALLENGES/OPPORTUNITIES•Replacement of old claims application•Need to gain efficiencies in the back office •Needed timely management information support to support externalreporting requirements and provider network comparative analyses

SOLUTIONSOracle OpenZorg, Oracle OpenBeleidOracle General LedgerOracle Database 10g, Oracle Fusion Middleware 10g

RESULTS• One of the lowest number of FTEs for claims

processing by electronic exchange with Healthcare Providers

• Azivo was awarded as being the fastest (mandatory) reporting Healthcare Payer in the Netherlands. Before implementing Oracle OpenBeleid it was one of the slowest in reporting.

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Unive-VGZ-IZA-Trias (UVIT)Largest Dutch Healthcare Payer

CUSTOMER PERSPECTIVE”Oracle OpenZorg is of strategic importance to VGZ-IZA. The multi-year contract reflects our confidence in the continuity Oracle can offer us.”Chris Driessen, Board member

COMPANY OVERVIEWThe Netherlands’ largest Healthcare Payer, Unive-VGZ-IZA-Trias insures more than 4 million people and manages an average of 200,000 claim lines every single calendar day.

CHALLENGES/OPPORTUNITIES•Needed the agility to respond rapidly to frequent, complex changes in Dutch healthcare insurance law•Operate industry best-practice policy and claims management processes within an integrated IT environment •Analyze costs of providing healthcare insurance and assess profitability of individual and collective policies in portfolio •Streamline mandatory reporting to external regulatory bodies •Cut IT management costs by eliminating the need to build and maintain interfaces between more than 100 applications

SOLUTIONSOracle OpenZorg Oracle OpenBeleidOracle Self-service Insurance (based on Siebel edocs)Siebel CRM for call center Oracle Database 10gOracle Fusion Middleware 10g

RESULTS• Before implementation of Oracle OpenZorg

VGZ could not handle the increasing volumes anymore. Afterwards it has reached unlimited scalability in order to enable its Merger and Acquisition strategy

• Implemented business processes from head to tail; Oracle web application, backoffice, analytics and call center

• VGZ reduced the number of applications and interfaces significantly

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The Oracle Difference

•Only Oracle Self-service Insurance complete off the shelf payer-specific solution for recruitment and enrollment of new members•Only Siebel CRM offers payer-specific call center and off-the-shelf payer intelligence for all channels•Only Oracle OpenZorg offers fully automated claims adjudication engine checking all health plan definitions and provider agreements•Only Oracle OpenBeleid offers off-the-shelf analytics for claims and member data combined

Only integrated off-the-shelf modular solution from front- to back-office with analytics

Only Oracle…

Healthcare Payer Solutions (EMEA)

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