1. Background In 2021, Huiminbao received a total of 14 billion yuan in premiums in 28 provinces and 244 prefecture-level cities across the country, and received about 140 million customers. In the first half of 2022, Huimin Insurance had a total of 66 million people participatin

. Background

In 2021, Huiminbao received a total of 14 billion yuan in premiums in 28 provinces and 244 prefecture-level cities across the country, and received about 140 million customers.

In the first half of 2022, Huimin Insurance had a total of 66 million people participating in insurance, with a premium of 6 billion yuan; and it covered a wide range of areas: 235 cities in 26 provinces.

Huimin Insurance market is very lively, but factors such as Huimin Insurance products have small profits and quick turnover, and the pricing method based on high compensation rates under the leadership of the government have limited profit margins for pure Huimin Insurance business. With the development of Huimin Insurance, the platform faces a question: How to make it bigger and stronger? Various attempts that can be seen in

, such as health management, special medicine services, one-stop settlement, commercial insurance catalog, etc.

Among them, the profit margin of health management and special drug services is limited, and even the compensation risk in some areas (especially areas with severe aging and past symptoms) is also very high. Moreover, even if a certain profit can be obtained, in some projects, cooperation with the government is "zero commission" only depends on the profit coverage of health management and special drug services, and cannot realize value income.

For one-stop settlement and commercial insurance catalogs (excluding special medicine catalogs, the same below), some cities are led by the Medical Insurance Bureau, while others are built by the People's Welfare Insurance Platform. Among them, the premise for realizing the commercial insurance directory is to connect payment, that is, one-stop settlement, because only by connecting payment can you achieve management, risk control and other means for the commercial insurance directory, as well as convenient calculation and claim services without any effect. After one-stop settlement opens up payment, it has the possibility of gaining more opportunities not only in the commercial insurance catalog, but also in hospital management, fee control, medical resources, commercial insurance procurement, etc. Therefore, the author believes that one-stop settlement will be an important step in Huiminbao's next development, and even a necessary path. However, the initial investment (money and time) of one-stop settlement is not small, and you need to see clearly about the future, have enough strength to persevere, and have a boss who can understand it and an open-minded medical insurance bureau.

2. Concept

One-stop settlement is different from the so-called direct compensation and fast compensation services, and it is much more advanced and advanced.

, The so-called quick compensation is to open up a medical data channel through a third party or directly with medical insurance or health care or hospitals. Medical data can be obtained before or after the patient submits the claim, but the patient still needs to submit a claim application, bank account information, etc., but the claim information can be simplified and the claim settlement speed is faster. However, due to the requirements of insurance companies for some basic rules for risk control, quick compensation does not apply to all customers. At the same time, because the claim application process cannot be avoided, users have relatively weak perceptions of the service.

For example, Shanghai’s “Huhuibao” is a concept similar to the fast compensation. Fortunately, the characteristics of Shanghai Huibao products - the previous symptoms can be insured and compensated, and the identity of the people with the past symptoms will be marked when insured - simplifies the subsequent calculation and risk control process, and the fast compensation experience is relatively good. If the user has completed interaction when his or her medical data is submitted, the review can usually be completed within 24 hours.

and The so-called direct compensation is to open up medical data channels through a third party or directly with the hospital. Patients do not need to apply for a claim and complete settlement at the hospital. The compensation is directly paid by the hospital or the insurance company will complete the payment upon discharge.Direct compensation services have achieved great progress in claim timeliness, but because they are completed through data connection with hospitals, the cost of data connection is high, and the degree of cooperation between hospitals within a certain administrative division is different, making it difficult to form regional coverage. Since commercial insurance settlement has a certain waiting time after medical insurance settlement, hospital settlement can usually only become a "model house", and it is difficult to achieve true regional or extensive service capabilities coverage. Moreover, due to factors such as personal information protection, customers still need to sign authorization materials during the hospital. For example, in Guangdong, Henan and other places, the direct compensation services launched by various companies fall into this category.

. One-stop settlement is that one-stop settlement is based on the construction of the welfare-oriented insurance scenario, and naturally correlates with the local Medical Insurance Bureau (the endorsement of the Medical Insurance Bureau is the basis for the long-term development of Huimin Insurance. I think the welfare-oriented products without medical insurance endorsement are not long-term and can only be done as an insurance business. Therefore, there is no significance and necessity of developing one-stop settlement. Therefore, medical insurance endorsement is a prerequisite for the welfare-oriented insurance business discussed in this article). The basic concept of

is to directly connect with medical insurance data, link and cover local hospitals through the core system, and then complete the payment of claims to customers in the form of advance payment of compensation at the hospital, and then the insurance company and hospital settle the settlement.

The advantages of is:

(1) and medical insurance data are connected, which is in line with the national conditions of the medical environment:

① Medical resources and medical behaviors are concentrated in designated medical insurance hospitals.

② my country's medical insurance coverage rate is high. As of the end of 2021, the number of people participating in basic medical insurance reached 1364.24 million, and the coverage of insurance coverage is stable at more than 95%. In other words, more than 95% of people in my country need medical insurance to see a doctor. Huiminbao's product design is also based on medical insurance.

③The medical insurance terms follow the principle of cost compensation, so they require that commercial insurance settlement be carried out after medical insurance settlement and connect with medical insurance data. This is the basis for rapid and direct commercial factoring, so as to achieve one-time settlement of medical insurance and commercial insurance at the hospital.

(2) Form regional coverage:

① Medical insurance can cover all designated medical insurance hospitals in this area, and the scope of this hospital is often ≥ the definition of "hospital" stipulated in the insurance company terms.

② is efficient and low-cost compared to data communication with hospitals.

(3) Really convenient for the people: the best service is that there is no service, the settlement will be made immediately after discharge, and there is no feeling in the claim.

(4) Extensibility: build a commercial insurance catalog, commercial insurance fee control, hospital management and commercial insurance centralized procurement technical basis.

(5) Information authorization can be pre-ordered to the time when taking out insurance. Huimin Insurance obtains the authorization of medical insurance data and personal data every year to solve the problem of submitting claims materials during back-end claims.

3. Application scenarios:

takes the construction of a one-stop settlement platform as the key point for further expanding the commercial insurance and drug consumption catalog for welfare insurance business.

. Expand merchant insurance : a regionalized full commercial insurance payment platform.

One-stop settlement for welfare insurance → One-stop settlement for medical insurance → Other health insurance commercial insurance payment functions are expanded.

, Drug Consumption Directory : Commercial Insurance Directory and subsequent technical basis for cost control and centralized procurement.

The word "官网" in Huimin Insurance is reflected in "cheap prices and sufficient quantity". The coverage is large and the coverage is wide, and the corresponding operating cost control and risk control capabilities are higher. After one-stop settlement is realized, the operating cost is compressed to a very small range and can achieve refined risk control operations. Moreover, this risk control operation is common and habitual by the Medical Insurance Bureau and is easier to recognize.

At the same time, the centralized procurement of drug consumption can further reduce the compensation pressure and achieve universal benefits. It also gives Huiminbao platform more room for business imagination.

4. The value of pain points sorting out and one-stop settlement of all parties:

. Insurance company:

(1) What should I do if I wear it if I have to wear it?

As mentioned above, under the pricing based on high compensation rates, the risk of not spending enough money exists.

Take Shanghai's Huhuibao as an example. As of July 20, 2022, the total compensation was 750 million yuan, the total premium income was about 850 million yuan, and the compensation rate was 88%. This is still the case that Shanghai has been quarantined for three months due to the epidemic, which has greatly reduced the number of hospitalizations. Moreover, there are still factors such as outstanding cases and users who have not applied for claims. The compensation rate is only high and not low. If the various costs such as early system construction, promotion of various channels, advertising and other costs are obviously a money-loss project.

Solutions can be:

① not done.

Government pressure, large-scale premiums, millions of users, early investment, future imagination... This option is obviously not good enough.

② Reduce costs.

front desk cost will not be discussed in this article. The cost of the middle and backend of

includes operational costs, compensation expenses, etc., and one-stop settlement can be solved.

For operating costs, opening up the payment channel at one time means that most of the costs of claims acceptance, calculation, and claims personnel have been solved by most of the systems. Only a small number of personnel are responsible for the situation of reimbursement of medical treatment in other places and hospitalizations after full self-payment.

For compensation expenditures, as mentioned above, in the scenario where the previous symptoms of Huimin Insurance can be insured and compensated, the focus of risk control is on cost control. The investigation and punishment of medical abuse, medical fraud and other behaviors, and the control of drug consumption, commercial insurance catalogs, etc. all need to be completed based on the systematization of payment, which is the significance of one-stop settlement.

③ Increase pricing.

pricing can be increased, but it cannot be increased without restrictions, otherwise how can we talk about benefiting the people?

Therefore, it is not as important and feasible to increase pricing than to reduce costs.

At the same time, pricing and product design are synchronized, which is also closely related to the accumulation of claims data. After one-stop settlement is opened, more support can be given to the precision of data accumulation and the convenience of data analysis.

(2) How can the welfare insurance business continue?

① Single welfare insurance business achieves stable and small profits. This answer naturally also requires the role of one-stop settlement in cost control, which is similar to the above.

Of course, there are other front-end problems that need to be solved, so this article will not be listed.

② Expansion and secondary sales of insurance products based on welfare insurance.

From the product perspective, if the subsequent expanded products can achieve direct payment in the hospital within the region based on a one-stop settlement platform, it will be more attractive to local people; at the same time, the accumulation and refined management of claims data can also be fed back to product design and pricing.

What we are talking about here is the value of one-stop settlement, not just this one (this sentence is precise).

③ Other income based on Huimin Insurance, such as health services, drug consumption, risk control services, etc. If you see the previous text here, do you find that one-stop settlement is still in urgent need?

. Medical insurance party:

One of the functions and tasks of medical insurance is to complete the construction of a multi-level security system. Therefore, medical insurance bureaus in many places have shown a very positive attitude towards benefiting people. Therefore, for medical insurance parties, they need:

(1) To be killed, to be buried, to be sold, to be compensated. To complete the construction of a multi-level security system, selling insurance is only the first step, and the result is to lose money in real terms. From the perspective of medical insurance, the traditional claim processing process of commercial insurance is unreasonable and has no service value. Medical insurance is thinking about how to make patients wait at the entrance and exit, the shorter the better. Commercial insurance is still asking patients to collect and submit tedious claims materials. The gap between the experiences is huge, and one-stop settlement is the ultimate way to "manage compensation".

(2) How to develop sustainablely in Huimin Insurance, or how to enable commercial insurance companies to continuously underwrite within the scope of small profits, no losses or minor losses.

The Medical Insurance Bureau can accept commercial insurance to make profits, but will not accept making big money (it will not be "benefited". Small profits and quick turnover are the principle, and even flat in and out. Similarly, in the medical insurance undertaking of serious illnesses in some areas, medical insurance will set profits and losses, such as 2%, loss of more than 2%, medical insurance will be supplemented, and if the business insurance company that makes more than 2% of the money is made, the commercial insurance company that undertakes finds a way to spit it out.

(3) How to help the people-friendly insurance business parties to do a good job in hospital management.

"2021 Medical Insurance Development Statistical Report" shows that in 2021, a total of 708,000 designated medical institutions were inspected and 414,000 illegal and irregular institutions were dealt with, of which 4,181 were terminated, 7,088 were administratively punished, and 404 were transferred to judicial organs; 45,704 insured persons were dealt with, of which 6,472 were suspended for medical insurance card settlement and 1,789 were transferred to judicial organs. As of the end of 2021, a total of 23.418 billion yuan of medical insurance funds were recovered (a total of 22.311 billion yuan of medical insurance funds were recovered in 2020). 30 flight inspections were organized, and 68 designated medical institutions and 30 medical insurance agencies were actually inspected in 29 provinces, and 558 million yuan of suspected illegal and irregular funds were found.

However, the above-mentioned medical insurance bureau’s inspection and handling behaviors of medical institutions cannot be carried out by commercial insurance, but the same problems with commercial insurance exist, such as medical consumption abuse, bed hanging, medical fraud, etc.

In the welfare insurance business, due to the wide coverage of welfare insurance, it will soon be noticed by medical institutions. Then the same behavior will occur, and the corresponding inspection and processing mechanisms are required.

Medical insurance needs to empower its own experience and capabilities to commercial insurance, and commercial insurance needs to have a smooth mechanism to report problems found to medical insurance in a timely manner. Among them, one-stop settlement can complete the output of the intelligent cost control capabilities of medical insurance to commercial insurance and the prompts of the intelligent medical insurance violation risks to medical insurance, as well as the management and fee control of the commercial insurance catalog.

. Pharmaceutical companies:

In commercial insurance:

(1) In addition to special medicines, how to continue to explore opportunities for other commercial insurance. When pharmaceutical companies communicate with commercial insurance companies, the problem that often encounters is that pharmaceutical companies hope that commercial insurance can use their customers and claims resources to help sell drugs. Commercial Insurance hopes that pharmaceutical companies buy insurance and patient sales, which looks pretty, but cannot continue.

(2) Under the background of centralized procurement, how to reduce prices and sell more medicines. The price of the "soul" obtained by bargaining "soul" is of quantity but priceless. Is it possible that you can achieve sales goals without bargaining your soul.

(3) How to maintain or improve the research and development of new drugs under the background of centralized procurement. New drugs have high cost and no reasonable profit incentives, so why do you need to develop them? Some experts say that centralized procurement depends on the general background, saying that it can improve lifespan and promote the economy, and it must look forward to the long-term. I said that he saw that he entered the coffin without considering the long-term nature of the pharmaceutical industry. The long-term nature of the pharmaceutical industry is positively correlated with the long-term nature of the general health of the people. If he entered the coffin himself, he did not consider future generations?

(1) (2) The commercial insurance catalog is the direction, through the universality of welfare insurance, it connects commercial insurance payments and pharmaceutical companies; (3) In addition to self-payment, it can be reasonably priced and managed by new drugs based on the commercial insurance catalog. Having a payer will help to open up sales. Only with sales will there be profits, and only with profits will there be motivation; medical insurance cannot suppress the enthusiasm of pharmaceutical factories for new drug research and development in order to reduce prices, and requires a long-term vision. If it is not suitable for centralized procurement or the centralized procurement price cannot satisfy medical insurance or cannot afford it, then it will be transferred to commercial insurance as a payer. Commercial insurance manages new drugs through reasonable pricing, and pharmaceutical companies can also appropriately compliantly feed back to commercial insurance to seek a balance point of profit.

Commercial Insurance Directory is a must-have item, and the "must-have item" must-have item is one-stop settlement.

. Patient: I still only spend so much money, I want more.

(1) Medical expenses:

According to statistics from various places, for hospitalized patients, medical insurance payment can cover about 50-55% of the fees, and other expenses must be paid by the patient. For self-paid expenses, you can:

① only pay medical insurance, not buy commercial insurance. You will bear all the out-of-pocket expenses yourself. The medical insurance payment capacity has reached its limit, and the effect of centralized procurement always has a peak. The patient is burdened.

② Pay medical insurance and purchase other commercial insurance. People with previous symptoms cannot cover it, it is difficult to apply for commercial claims, and the pricing is expensive.

③ Pay medical insurance and purchase welfare insurance. Covering people with previous symptoms, easy claims and universal pricing.

If Huimin Insurance is the future, then based on the previous discussion, future sustainability requires one-stop settlement.

. Platform: In addition to existing special medicines, health services, and brokerage fees, what other income points do you have?

. The value of one-stop settlement platform.

(1) Positioning:

Bridge.

commercial insurance and drug payment platform.

First open a city, then gradually open up existing cities and form a complete solution to expand new areas.

(2) Mode:

(3) Barriers:

occupy the payment channel and occupy users and data.

(4) Value:

Commercial Insurance: Open up payment, reduce costs and increase efficiency, and empower front-end sales.

Pharmaceutical companies: Enter the commercial insurance catalog, expand sales, and drive R&D.

User: Convenient claims and inclusive insurance.

platform: a platform for commercial insurance payment and drug consumption management.

. Problems and difficulties.

(1) Who will do it?

core manufacturers or platforms. This one needs to be grabbed.

(2) High investment.

initial system construction costs are relatively high, and the future profit time and size are uncertain. But the direction of efforts is clear and the story makes sense.

(3) Commercial.

monetization timeline is long. Welfare Insurance renewal once a year, and system construction and changes need to be consistent.

resistance from multiple parties. Although the consistency of interests is large enough as mentioned above, there are conflicts of interests that need to be balanced and promoted.

(4) Who leads.

Medical insurance, platform or manufacturer. Business value cannot be said the same.

. How to do it.

(1) Persistence, especially the high-level recognition of the enterprise.

(2) Human resources: products and technology. Understand medical insurance, risk control, and claims processing.

claims and products: understand claims, understand claims automation solutions.

technology: It is best to have experience in core systems and (or) business insurance.

Otherwise, there will be too many details that are easy to omit, and both of the above must be included.

(3) Cost: technical cost, labor cost.

Many details are hard to describe in one article, and many clues are hard to understand.

Welcome to exchange and discuss!

Recommended reading: Medical Insurance Research on the cost control effect of different drug procurement models, looking at the future of commercial insurance risk control