Health Insurance and
Risk Management systems

Risk Management

Omni allows real-time control of products and benefits that allows the insurer to:

Key Features

Make manageable actuarial decisions rapidly with relevant and up-to-date information
Understand, report and control utilisation of benefits down to member level
Control benefits through flexible product configuration allowing tighter limit control - Omni can control limits by:
Time - day, week, month, year By benefit available
Provide a framework where TPAs operate the same system enabling insurer to outsource administration but retain the control of risk

Benefits & Products

Omni allows complex products with base/rider product relationships to be defined by users literally in minutes.

Products are defined for a particular underwriter and defined set of benefits. Benefits have associated rules that drive the automated claims adjudication process and overall policy management process. Associated with each product or product option is a Rate Card that controls the premium calculation using premium factors such as date of birth or salary, or tabular rate concepts.

Rules Engine

Omni uses a dedicated rules engine to define benefits. Rules are assigned to benefits and allow for wide flexibilities in limits. Multiple rules may be applied to single benefits and the same rules applied to other benefits:

Financial - benefit $ limits with inner and outer values e.g. limit per procedure, limit per annum, limit for policy lifetime
Numeric e.g. number of doctor visits

Key Features

Define products and benefits for Health and Risk products (Life, Income, Trauma, TPD...)
Define multiple benefits types
Define benefits and adjudication rules
Link clinical code sets to benefits
Assign Relationships between products and benefits
Create base and rider products and product bundles
Assign different (excess) options to products
Assign underwriters to products

Groups & Group Plans

Omni Group and Group plan model allows either single or bundles of a base/rider products from diferent underwriters can be offered to a Group. Different products are placed in Group plans and offered to members of the Group. Omni contains a flexible structure allowing the breakdown of a group into plans, and further into the internal divisions (or business units) of the Group to assist in the billing and cash match of premium received from the Group or member, primarily by payroll deduction or direct debit agreements. During Group plan establishment, all member details may be loaded into Omni using a standard Policy Upload interface to automatically create all policies and calculate the initial installment and annualised premium per policy.

Policy Administration

Once the Group and plans are in force, Omni allows the administrator to use a number of screens to update member and policy information online with a detailed audit being maintained.

Policy maintenance includes simple updates like address and contact information, through to more complex options like updating the member’s billing and receipt details, or banking details for claim payments and direct debit receipts. Many updates can affect the premium, such as adding or removing members, changing the product option, or changing factors that directly affect the premium calculation such as date of birth, salary or smoker status. All updates that affect premium can be backdated.

Key Features

Define Groups, divisions and locations
Define Group contacts and advisors
Define start and next renewal dates for groups and plans
Link Group plans with products and product bundles
Define Group plan subsidy levels, and how both subsidised and unsubsidised portions will be paid
Assign premium calculation methods, billing methods and frequency to a Group plan
Assign valid product (excess) options per plan
Place plans in force, print welcome letters and acceptance certificates
Multi-step group renewal process and premium recalculation

Key Features

Define products and benefits for Health, Travel and Risk products (Life, Income, Trauma, TPD...)
Define multiple benefits types
Define benefits and adjudication rules
Define multi-level hierarchies of clinical codes
Link clinical code sets to benefits
Assign Relationships between products and benefits
Create base and rider products and product bundles
Assign different (excess) options to products
Assign underwriters to products
Assign underwriter and administrator rate cards to products

Underwriting

The Omni system supports multiple underwriters, and for different products to be de ned per underwriter. Various controls and information can be provided to each underwriter within tight data security that is limited to only that underwriter. A set of parallel accounting is generated online within Omni for both the administrator and each underwriter using the underwriter’s own general ledger account codes. Various accounting and other extracts or reports may be requested by the underwriter logging onto Omni over the internet via a secure layer. Omni allows online access to information such as claims monitoring, and the ability for the underwriter to make certain pre-agreed authorisations, such as payment of claims.

Claims Management

Claims and Prior Approvals are managed within Omni for hospital and primary care claims. A claim can automatically be generated from an authorised Prior Approval. Multiple claims can be linked together so that grouping of treatments can be made even though a number of claims are submitted over a period of time. Each claim and Prior Approval must step through an adjudication process where the Omni system performs a series of checks using a rules based engine.

Key Features

Handles multiple underwriters in a single instance
Define unlimited products per underwriter
Define product bundles spanning multiple underwriters
Underwriter database includes payment details, contacts, account codes, occupation classes
Run and download accounting extracts online
Download a period data warehouse extract online
Review Prior Approvals, claims and medical invoices
Authorise Prior Approvals, claims, claims payments and medical invoices

Premium Accounting

For each member in a Group and product (excess) option Omni calculates the total premium, tax, installments and risk portion based on member demographics using a list of Rate Cards for products and underwriters. Omni supplies a powerful billing tool with flexibility to cover various premium rates, billing frequencies from weekly up to annual billing. After the billing has been run to raise premiums, direct debits can automatically be created, or in the case of direct credits or cheque payments, these may be entered and then matched automatically against the premium raised through either matching against the installments premium for the policy or a manual match at member product level.

Premium Calculation Features

Multiple rate cards for underwriters and product options
Tabular and premium factor based Rate Cards available
Automatic premium calculation of premium and tax
Online premium recalculations within policy administration

Premium Accounting Features

Raises premium at levels from Groups to a single policy
Includes a preview mode for user review and a final mode
Creates tax invoices, Group payment schedules, and premium to be collected by direct debit agreements
Calculates credit billing, and credit/re-billing for retrospective changes to the policy and premium
Optionally prorates the premium raised in a period for member or product change during a period

Member Benefits

The Omni Benefit Plus module offers employees the choice of benefits they want or need from a package of benefit programs offered by an employer – either fully or partially subsidized, or as optional benefits that are offered to employees that will be self-funded. The Omni Benefit Plus module allows flexible benefit plan employees to contribute all or part of the cost of these benefits through a payroll deduction of their gross income, reducing the employer's contribution.

The Omni Benefit Plus platform provides extensive support for self-administration of flexible benefits through a member portal where members can select and manage both health and non-health options that are provided. The types of benefits that can be supported are configured in the Omni product and benefit configurator and therefore allows for the creation of a wide variety of flex products.

Claim Entry

The Omni Benefit Plus system allows members to enter claims for reimbursement. Once entered, the claim is passed to Omni administration staff to be processed under the strict rules and adjudication controls supported. These adjudication rules can be configured to your requirements.

Members can view claim progress as well as product cover options prior to claim entry.

This allows members to see rapid completion of the claims and payment process. This is achieved by allowing the direct input of a large volume of claims into the system by members, and real-time analysis of claims, fraud detection and controls under the claim adjudication engine rules, and loss ratio management control.

The coupling of the Omni Benefit Plus front end to the Omni administration engine is a unique construct allowing overall, superior risk management.

Health Insurance and Risk Management systems

Risk Management

Key Features

Benefits & Products

Rules Engine

Key Features

Groups & Group Plans

Policy Administration

Key Features

Key Features

Underwriting

Claims Management

Key Features

Key Features

Premium Accounting

Premium Calculation Features

Premium Accounting Features

Member Benefits

Claim Entry

Health Insurance and
Risk Management systems