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Health Insurance Organization (HIO)

Building Capacity at Egypt's Health Insurance Organization

The Ministry of Health has initiated major reforms to substantially improve health outcomes and the financial sustainability of Egypt's health care system. A key component of the reform is the separation of financing from provision of care at the Health Insurance Organization (HIO). The mission of the HIO is to become an effective health care services enterprise able to design, price, negotiate, contract, and pay for services covered under Egypt’s social health insurance scheme and to ensure high-quality health care services for all Egyptians.

As the HIO transitions to a “pure” insurance company, it requires a medical management system consisting of two functions:

• Ability to audit the compliance of contract specifications with the health care facilities with which it contracts
• A utilization and case management process to ensure that the care it pays for is medically necessary and appropriate – a critical function to ensure the HIO’s financial stability and sustainability

To assist the HIO in its transition, Health Systems 20/20 has trained HIO auditors to evaluate compliance with contract requirements and accreditation standards. This training has included classroom courses, observation of a "mock" audit in three selected HIO hospitals, and practical training in doing an audit under observation of an experienced international audit/survey expert. Trainings have been conducted at four HIO hospitals (Nasr City Hospital in Cairo, 6th October Hospital in Giza, Gamal Abdel Nasr Hospital and Student Hospital in Sporting in Alexandria). After completing the training, participants took a written exam to be certified as auditors and sixteen were awarded a certificate.

Health Systems 20/20 has also trained utilization and case managers in the principles and practices of utilization and case management and provided practical “hands-on” training in reviewing medical records to evaluate whether documentation supports diagnosis and justifies treatment.

Health Systems 20/20 conducted an intensive two-day utilization management program and medical audit orientation for 21 regional HIO directors. The orientation was followed by a one-day introductory workshop on utilization management and case review, consisting of course work in the principles and practice of utilization and case management. Since HIO will need to evaluate the medical records of its beneficiaries to determine if the care for which it pays is medically necessary and appropriate, the utilization managers received practical training in medical record review to evaluate whether the documented medical record supports the diagnosis and justifies treatment and supports the continuity of care for the HIO beneficiary.

The project will train another cohort of auditors as well as utilization and case managers and will provide ongoing “coaching” as the trained HIO personnel further refine their skills.