Internship graduation Report

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Student Name: Amal Qasim Mohammed Ahmed

Internship start: 13 Jan 2019

Internship Finished: 21 Mar 2019

Working hours: 8 hours per day 40 hours per week

Company name: Saudi Enaya for health insurance

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Table of contents

Executive Summary ...................................................................................................... 3

Company Description ...................................................................................................... 4

Product & Services …………………………………………………………………………………………………… 5

Saudi Enaya Organizational Structure……………………………………………………………………………. 6

Internship Activities ………………………………………………………………………………………………………. 7

Organization Layout & responsibilities............................................................................. 8

Product and services flow …………………………………………………………………………………… 9, 10, 11

Saudi ENAYA Departments ……………………………………………………………………………………… 12, 13

Quality & Control ………………………………………………………………………………………………….. 14, 15

Comparison Theory ……………………………………………………………………………………………………… 16

Assessment of Internship …………………………………………………………………………………………….. 17

Conclusion …………………………………………………………………………………………………………………… 18

Appendix ………………………………………………………………………………………………….. 19, 20,21,22,23

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Executive Summary

Saudi Enaya is a Saudi company specialized in health insurance, offering first class product and qualified services for groups and individuals.

It has a different scale of product which can be suitable based on the client requirements and the demographic coverage needed.

Saudi Enaya consist of full structured organization with different departments that work together in managing the insurance policy cycle and to keep the work going on in a smooth operational structure

My internship was in provider network which is the department that I officially work in Saudi Enaya as I am an employee in since Mar 2018, in that department we focus on the healthcare providers and all related services.

most of our activities in Network department are administration work, it consist of building the relation with healthcare providers at first in types of agreement to provide services to policy holders, those services are in type of access to their facilities based on provided health coverage, also part of this agreement is the payment agreement to those providers, some type agreement comes in the form of monthly payment and some of it as the form of commercial agreement on a particular period with an agreed percentage. And before we start the payment we had to create a type of calculation for the amount submitted by the provider in order to get the accurate amount.

aside to the regular administration work, good relation and financial structuring we had the fraud and abuse unit which I had assigned to work within that unit to manage with an assigned doctor, our work in fraud unit was to identify the healthcare providers who are creating a misleading activities and submitting falls billings that could end up to be a major loss to Saudi Enaya.

while managing the good relation with the providers we have to be sure to keep all parties in the insurance relation linked together as without finance department, Sales , marketing & compliance our work will not be completed as most of the job required their interference and support to accomplish a task.

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Company Description

Saudi Enaya for corporative health insurance known as Saudi Enaya was established in 19 February 2012, it's a public company on the stock exchange (Tadawul), Enaya is engaged in the insurance sector with a focus on life and health insurance.

Enaya Structure

 Munich Re 15%  Al Watania for insurance 10%  Mohammed & Waleed Al Naghi 5%  Dana Khaled Juffali 2%  Mazen Fakeeh 0.038%  Faisal Tammr 0.0025%  Lee Chory 0.0025%  Khalid Al Jaffali Holding Company ( unknown percentage )

Board members

Faisal Farouk Mohammed is the Chairman of the Board of Directors

Daniel Whitehead Chief Executive Officer

Bilal Talal Al Ghazzawi Board of Directors

Dana Khaled Al Jafal Board of Directors

Mazen Soliman Faqih Board Member

Cornelius Alexander Lons is a member of the Board of Directors representing Munich Reinsurance

Johan Michael Petzer is a board member representing Al Watania Health Insurance

Contact Information

Jeddah, Saudi Arabia

Khaldiah, Prince Sultan Street, BOX 3528, Jeddah 21481

Telephone: + 966 12 5923 500

Fax: +966 12 5923 741

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Website: www.saudienaya.com

Email: info@saudienaya.com

Product and Services

Saudi Enaya products are a range of different categories of health insurance coverage that can be suitable for organization and individual as well as the product are compliant with the requirements of council of cooperative health insurance. As they have a flexible options available for customers that they may wish to have a different level of coverage depending on the employees rank or position within the company.

Saudi Enaya offer different products such as

Diamond, Gold, Silver, Bronze & Classic, each product has its own unique coverage aside to the main requirements of CCHI which is the base to any insurance coverage add to that the unique features such as international coverage, in patient benefits as well which include the type of room in case of admission, also the option of increasing the dental and optical coverage.

all that within the wide network of providers across the Kingdome as Saudi Enaya Have more than 1000 Providers including Major Hospitals, Polyclinics, Diagnostic Centers, Dental Centers, Optical & Pharmacies and not to forget the coverage in ministry of health hospitals and centers, those providers are located based on demographics requirements of Saudi Enaya Clients, and not also to miss the CCHI minimum requirements for each region as for each region in the kingdom we have to provider a number of hospitals and polyclinics for our members

Those members can differs from each other as we have the factories which have normal labors and require minimum coverage in a remote area, to a large organization with fully structure or executives to middle managers and employees. As those clients are the members who will get the benefits out of the policy that they will purchased for their workers.

Employment structure

 Saudi Enaya has a total of 140 Employees, 42 are women’s and 98 Males with 52.9% Saudiazation

 17.9% on the managerial level and 82.1% staff

 Maximum services years 50% of employees will stay for 3 years

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Internship Activities

My work in the provider relation network department under the supervision of Dr Mohammed Shawky as he

is the manager of the department, the network team consist of region each region are managed by a team of

two or more, I am working in the western region as the supervisor of Makkah & Jeddah our objectives in

Network team is to create a network of health care providers which they provider high standard quality

services to our members with an agreed price through a competitive agreement that can manage the cost of

medical treatments for our members. Aside to that is sustaining the relation with the providers through

meetings & calls

Recently I was assigned to fraud unit to manage the detection of abuse and fraudulent activities by providers.

Department Layout

CMO - Dr.Essam Masood

Network Manager Dr.

Mohammed Shawky

Zain Adam – Admin

Supervisor

Ahmed Salim

Northern & Southern Region

Dr. Haytham Eastern region

manager

Ahmed Al Sayed, Qasim

Sabir

Central Region Supervisors

Amal Ahmed, Mohammed

Irshad

Western Region

Samira

Admin

Razan

Admin

Amal

Admin

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Designation Responsibilities

Network Manager /

Network Supervisor

as per the instruction

of Network Manager

 Manage and facilitate the provision of requirements for reconciliation and settlement.

 Monitor efficiency & productivity of all the settlement process.

 Regulate department workflow stream.

 Initiate innovations to improve the process.

 Follow up with claims team for timely processing of outstanding claims

 Communicate with Claims / Authorization Department in case of any discrepancy or feedback.

 Cooperate with Claims and Finance to make sure the payments are effectively released on timely manner.

 Communicate with Finance to identify areas of improvement and find solutions to enhance the process.

 Demand and review the periodical reports of payments and settlements

 Ensure & assess protocol adherence, as mentioned in policy and procedures.

 Document any change in related Policy & Procedures, and report them to Network Department.

 Assess department performance.

Network Admin

Supervisor / Senior

Network Officer

 Train and monitor NW admin staff to fulfil the task requirements according to operational performance indicators.

 Review any issued reconciliation settlement prior signing it from the concerned area teams

 Identify issues related to provider payment and find solutions.

 Follow up with the team to work according to the standard KPIs.

 Ensure staff adherence to protocols.

 Provide admin team feedback to Network Manager.

 Supervise the Provider payment process.

 Circulate regular monthly outstanding settlement report to the regional managers to finalize the outstanding’s.

 Prepare & forward outstanding Payment Reports to Network Manager.

Network

Administrator

 Notifications of Summaries & Claims Reports to provider

 Receive Signoff Statements / Reconciliation letters from providers

 Update and forward signoff statements to claims and finance department

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 Prepare the full and final settlement letters and send to providers after signatures from concerned area team together with sign of Network Manager.

 Keep track of all signed and stamped statements and settlement letters in a shared excel sheet.

 Notify the Claims and the Finance of any signed reconciliations in maintain an efficient work flow process.

 Follow up with Finance until the payment is finalized.

 Send payment notification to the concerned providers.

Product & Services Flow

Healthcare provider Payment Settlement and Reconciliation

 Each month providers sent full statements of account with the invoices of services provided to our members, arranged by group and by date, providers also provide an excel sheet that contain invoices details for an easy upload of those information.

 Once Batch is register by Claim Department, the system identifies the (prompt payment) payment agreed between Saudi Enaya and healthcare providers, once Batch are processed within a particular number of days Saudi Enaya Have the right in a discount.

 System sends Automated Alert Mail to Finance

 Finance Team process in system and makes transaction updates their records

 Once Batch is processed and evaluated by Claims Dept. it’s posted at the System.

 Finance department clears the payments of Approved Amounts for processed and posted claims batches and updates the record.

 Once claims batches are processed and posted by claims department, system will alert network team to notify and send claims summary statements and report to providers.

 Once claims summary statements and reports reviewed by provider and agrees to the approved claims sends back the signoff statements to network team

 Assigned Network Dept. Admin updates the status of relevant batches as closed at the settlement / reconciliation-tracking sheet.

 Assigned Network Dept. Admin send notification mail by attaching relevant signed off batch statements to claims team for updating their records

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Example of Claims Statement

 In case provider does not agrees and resubmits the claims within acceptable period with proper justifications from all aspects, claims team will re-evaluate the claims.

 Claims department will send the re-evaluated reports to network team

 Network admin team will send the re-evaluated summaries and reports to provider copying concerned area network team for signoff the statements

 If provider disagrees to percentage for re-evaluated claims, concerned area provider network team has to review the reports and to communicate with provider and pursue to signoff the statements.

 If provider still declines, then to schedule meeting preferably for claim-by-claim basis or commercial settlement is done by meeting and upon agreement full & final letter will be sent to provider

 Concerned area Network Manager / Supervisor must review the rejected claims report; observe for major rejections and any abnormal claims behavior.( Fraud Unit )

 Any fraudulent or suspicious behavior is noted, dig deeper and cross check the physical claims

Thoroughly and keep it handy for reference, postpone the meeting

 All the observed trend and behavior is to be clarified at meeting with provider and pursue to avoid the same at future claims.

 Once the meeting / negotiations done report the details of conclusions and seek approval from Network Manager for percentage.

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 Once final SF percentage is agreed, take official confirmation from provider and forward the request to

admin team for preparation of full and final settlement letter.

 Concerned area Network Manager / Supervisor are required to follow up with providers to obtain the signed letters and forward to admin team

Example of Sign reconciliation Letter

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Saudi Enanya Departments

Sales: Sales Department focus on SME (Small and medium sized enterprises) and corporate through direct

sales in main cities of Jeddah and Riyadh, and manage kingdom wide with a team of telesales aiming on those

clients.

Sales Department deals also with Brokers who are licensed and contracted to manage all kind of clients.

Underwriting: issue the quotation and determine the insurance risk and who much premium the client will

pay, insure that healthcare plan are CCHI compliant, and insure long term financial stability.

Membership: handle policies creation old and new, uploading members into CCHI portal and editing member

details such as addition or dilation.

Customer Service: Received call through directed number from members and providers, immediate action

for members request, handling complaints, keeping members satisfied

Medical Approval: handle Authorization coming from providers for our members, refer members for second

opinion or in case the service wasn’t available, medical team has to ensure all decisions were taken within

approved Policy

Claims: insure of receiving, filling, evaluation medically and technically of all received climes

Provider Relation: create the healthcare network with quality services within affordable price. Establish

strong relation with providers to manage reconciliation and agreements.

Finance: handle all payment related to trade or providers, customer transactions, creating external report

and internal managerial report.

IT: IT departments consisting of four levels of restructure

 Enterprise application

Electronic claims

Quotation Admin

Reports and analyses

E-Comm

E- Services

Policy Admin

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 Application Integration

Integration between web server and external system (SADAD,WASEEL,CCHI )

Integration between web server and interface table( SMS, E-Business)

 Presentation Layer

Mobile APP

IVR –Self services

E-services

Provider Portal

 Interaction Channel

Customer on the phone

At Branches

Online customers

Customers at Providers

TOSHFA (Integrated Insurance Solution)

•Toshfa is Saudi Enaya system that provides a complete integrated insurance solution to meet all the needs

of current insurance industry as per the regulation requirement of kingdom of Saudi Arabia.

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Quality & Control:

 Restructuring Saudi Enaya Quality System based on current process flow

 Reengineering the current process flow

 Amend the process based on the reengineered business process

 Continues improvement and review in order to maintain enhancement.

Saudi Enaya has developed a quality management System (QMS) which has been completed around 75% of

its progress, it include operation procedures, work instruction and the major standard policies.

All documentation which was approved is available in quality folder, and to have an access to this folder you

need to have an approval from quality department.

The quality folder is subject to internal quality audit in order to check if departments are complying with the

approved procedures.

Internal Audit will conducted through trained auditors under the supervision of quality department

The plan will be shared with all departments beginning of each year.

Quality Activities within provider network Department

In regards to quality assurance in the internship departments we had to be sure of several steps in order to

be sure of the correct process.

Reconciliation

 Check the updated data from claims tracking sheet

 Calculate the shortfall percentage and reevaluate the rejection notes

 Evaluate the extracted reports such as ( unit cost, average per visit, claimed amount,,,atc)

Example of analysis

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New contract (healthcare provider)

 Check validity of documentation ( CR, CCHI Certificate, MOH)

 Price comparison to be sure the agreed provider network

 Check region and area of provider

 Check the structure of population in the provider area

 Check availability of major specialties such as dental,OBGyna, internal medicine & surgery

Fraud & abuse detection

 Check received information about the case and validate presented scenarios

 Identify the involved parties

 Agree on the method of documentation in order to identify fraud activities

 Validate findings by checking extracted reports

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Comparison Theory

As I have studied for the last four years business administration while I was working I found out that not even

50% of what have I studied are been applied inside local or national organization, accept for multinational

organization, as they are more focused to change and globalization. They have continues thrift for change as

they know that’s it’s the trend.

For national organization they have a traditional standard, military way of distributing task, how the power

flow from up to down, which make it difficult for employees to express their concern about an assign task,

they have to follow the chain of command. I found it difficult to express my concern in my department and

had to go with what my management wants even though my job is more exposed to more than sitting in an

office and checking emails.

There was no chance of career path in Saudi Enaya or any type of incentives that can be added as a value for

the employee work, which keep the turnover rate not stable, as I have studied that there are type of rewords

can be giving to the employees for their work that keeps them satisfied. Even if they feel good about their

work they don’t get the appropriate appreciation.

Being employees for more than 11 years made me realize the type of organization that care about the

employee and create a training schedule that are suitable for each to enhance their knowledge, once the

organization worked on those they can be sure that her employees will be a life partner and will never leave,

as he will be loyal to that organization.

Going back to the type of local organization I am working in right now I was faced with the issue of not

following the rules of cooperative health insurance in regards to family insurance, I am a single mom and

supporting my daughter and as per the rule I should have insurance for her, and I had to submit the prove

that I am fully supporting my daughter and not getting any alimony from her father.

Those were some of the issue that I have observed in Saudi Enaya which comparing to what I have learned it

should be applied & to be revaluated by the board of management in order for them to keep the company

running smoothly.

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Assessment of Internship

Part of doing my internship in the same organization that I am working, made me focus more in the

responsibilities that was assigned to me, such as the regional structuring on the network I had to build my

relation with those providers more, through face to face meeting, continues calls with day to day daily task

sheet that contain the list of healthcare providers that I need to contact them and set a meeting with them in

order to identify their issues and to manage the reconciliation of outstanding payment.

Those meeting enhanced my communication skills as I had to know exactly the type of verbal response

according to the situation.

Fraud detection was vital tasks needed me to focus on reporting and analysing more, as without correct and

valid information we couldn’t build our case, also it enhanced my critical thinking to evaluate the situation by

studying the issue from all aspect & ask questions in order to understand before we take the final decision.

Working as a network supervisor and doing my internship in the same organization was challenging as I had

to manage my work and in the same time think what I need to feel like an internship. So I had to start

creating an atmosphere for that to know what I need to enhance in my personality while doing my job and to

demonstrate what I have learned. And I found out that in order to be professional in your job you need to be

educated, without proper education in the field that you desire you will not succeed even though you had the

experience to do the job and the right qualification, you will still be missing some point which are only going

to be identify by an education. Once you got it you will know exactly how to draw your path, you will predict

what you want to be.

Aside to that, going through my Bachelor degree made me set my next step… is it to go with a MBA degree or

to go for a professional certification. Going for MBA in business is a key point in any person career but being a

certified fraud examiner is major point in my career.

Working in fraud detection unit made me realise that I would like to be specialized in this field, and I did start

searching for more information and which institute I need to contact in order to be a fraud examiner.

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Conclusion Training and working in an insurance company was a great opportunity for me to add lots of knowledge and skills which I was missing, as I have explained before in my report it made me improve some of the areas in the work place and especially in the same department I am working in. Having a general view of Saudi Enaya made me create an understanding the size of restructuring and enhancement needed to grow in the market, retention rate is low either for existing customer or employees, the organization structure enable lots of opportunities for professional development, there is no chance for employees to have any type of growth. Organization had several losses through the last five years which was a continues of bad decision and uncooperative of departments, there is no type of well structure manual that can be a reference for such issue if it accrue again. 2019 is the year that Saudi Enaya started to identify the major risks that they were facing before and to accelerate the process to match the other competitors in the insurance market, with steady and firm steps in order to achieve high result by focusing more on employees as they are engine of the company, they need to know the power of engaging the employees in decisions and multifunctional departments and projects. Whatever the barriers are it needed to be broken to achieve whatever targets will be set in future.

End

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Appendix

A-Tracking Sheet

Has all the detiles of providers in westren region specially Makkah nad Jeddah , which include main information about the provider, rejection % , recived amount, open period and forcasted persentage based on provider behavior

B- Rejection summary: it has all the details of each month and how much was the rejection based on type

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D- Fraud reporting: start with identifying the percentage for each service type

SERVICE TYPE Total

Consultation 27,457.10

Dental 27,270.30

ER Services 25,469.84

Laboratory 57,342.11

Medication 145,193.79

Other OutPatient 215.60

Outpatient 6,076.49

Package Deals 68.20

Physiotherapy 59.53

Radiology 9,152.98

Vaccination 4,707.15

Grand Total 303,013.09

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