Abstract of Dissertation

Agency : Gap Analysis, Health Insurance System, Insurance Department
Objective : • To understand the functioning of the health insurance system of UAE • To understand the functioning of insurance department in GMC Hospital, Ajman • To study the difference in the health insurance system of UAE and India • To study the rejection rate and its major causes • To study the TAT taken for each process in the insurance department using DMAIC
Background : A new law has made health insurance coverage compulsory for every resident in Dubai starting next year. Presently more than a million residents are covered out of the two million residents in Dubai. Officials from the Dubai Health Authority (DHA) said many blue-collar workers are not covered and this new law will ensure that everyone has access to essential health services. The insurance scheme will start to roll out next year and will be completed by 2016. Many blue collar workers and many spouses of expatriates presently do not have health cover. When it goes into force, the new law will ensure that no work or residence visa would be renewed without a health insurance cover. UAE has 1.9 beds per 1,000 residents while the global average is 3.0 beds and that for developed countries is 5.5 beds.
Methodology : Using a service-oriented architecture approach we discuss systems architecture of hospitals, TPA’s and insurance companies in relation to various processes and applications, and highlight current challenges and prospects. Study design and methods a) Type of study: Observational study and descriptive study b) Location of study: Ajman, UAE c) Study subjects: Health Insurance system of UAE and Insurance department GMC d) Sample – Simple random sampling 54 e) Data (information) to be collected (1) Number of claims rejected and their causes (2) TAT of sending request, follow up and update (3) Total number of cases coming per day (4) Manpower present compared to the actual need
Findings : A more service oriented system is designed in relation with the existing system which can cater and resolve a lot of upcoming problems and reduce the burden of healthcare time, cost as well as increasing the efficiency of the insurance department by reducing the TAT. The services and elements are grouped according to functional and interoperability cohesion of the various functions in the insurance department keeping in minds the link of the department with other departments
Recommendations : A transition towards service-oriented architecture in health care must acknowledge existing health care systems and promote the functioning of this system with a few additions that will reduce the time, cost and increase the efficiency in the functioning of the healthcare system. This is more focused on patient ease and comfort. A service-oriented approach cannot entirely rely on common standards and frameworks but it must be locally adapted and complemented