Health plan benefits configuration is the work of setting up each plan's benefits and claim rules inside a health plan's core system, so that every claim is judged against the right plan. It is done mainly for health plans in the United States, which may sell hundreds of different plans and change them every year. Some of the software and services for it are built by companies with engineers in Pune.
What does a plan's set-up contain? A plan is a long list of rules. Here are three common ones. The deductible is the amount a member pays each year before the plan starts paying. The copay is a fixed amount the member pays for a visit. The coinsurance is a percentage of the cost that the member pays after the deductible. Beyond these, the plan lists which treatments need prior authorisation, how many visits of each kind are covered, and which doctors are in its network.
Say a health plan in Minneapolis, Minnesota, in the United States, launches a new plan for the coming year. The plan has a $2,000 deductible. It has a $25 copay for a family doctor and a $50 copay for a specialist. After the deductible, members pay 20% of hospital costs. An MRI scan needs approval in advance, and physiotherapy is limited to 30 visits a year. A configuration analyst enters each of these rules into the plan's health plan administration system. The software keeps a record of each rule and the plan document it came from.
Then the set-up is tested. The analyst runs sample claims through the system before 1 January. One test is a 31st physiotherapy visit, which must be denied. Another is a family doctor visit, for which the member must owe exactly $25. If a rule is wrong, it is corrected before real claims arrive.
A mistake here is costly. If the copay is set at $15 instead of $25, every family doctor claim for the plan is paid wrongly, perhaps tens of thousands of claims. Each one must then be found and corrected. So the work needs both care and good testing.
The configuration is used every day afterwards. Claims adjudication reads these rules for every claim it decides. Benefits configuration sets the rules once, and adjudication applies them to each claim. The same plans are also described to members and employers during enrolment, through benefits administration software. If the plan's rules there and in the core system do not match, members are told one thing and charged another. Checking that the payments come out right later is the job of payment integrity.