Health Insurance Management Project

This project aims to provide a comprehensive system for managing health insurance, relying on medical, administrative, and financial supervision to ensure fair pricing, procedural integrity, and protection of all parties involved in the insurance process (companies, service providers, and insured individuals).

The project addresses common issues in the health insurance market through a clear organizational structure and precise procedures, led by a competent doctor and a specialized team.

Secondly: Common Issues in Medical Insurance

1. Issues with Medical Service Providers

• Manipulation of medical service prices and unjustified cost inflation.
• Retention and exploitation of user data to issue recurring invoices or inaccurate claims.
• Deliberate or accidental mixing of:
  • Therapeutic medical services.
  • Cosmetic services not covered by insurance.
• ⚠️ This confusion can only be resolved by a specialist doctor with medical expertise and the ability to make accurate clinical assessments.

2. Issues from the Management Side (Administration)

• Laziness or delay in processing claims.
• Absence of accountability in case of loss or disruption of a claim.
• Poor coordination between medical, financial, and operational departments.

3. Issues from the Users' Side

• Enabling non-insured relatives to benefit from the insurance coverage.
• Misuse of medical coverage due to lack of awareness or absence of supervision.

Thirdly: The Solution Provided by the Project

1. Clear Administrative Structure (As in the Diagram)

Project General Manager

Overall supervision and linkage between all departments.

Main Departments:

• Medical Affairs Department: Assessing medical cases, distinguishing between therapeutic and cosmetic services, and reviewing the eligibility of services for insurance coverage.
• Review Department: Reviewing medical claims, auditing invoices, and detecting duplication or manipulation.
• Operations Department: Organizing the workflow of claims, ensuring prompt processing, and monitoring daily performance.
• Finance Department: Controlling costs, comparing prices with approved standards, and preparing transparent financial reports.

Fourthly: Workflow in the Project

1. Receiving the Claim: Registering the claim and verifying the eligibility of the insured.
2. Medical and Administrative Review: Accurate medical evaluation + Comprehensive administrative audit.
3. Payment or Justified Rejection: A clear decision supported by a medical and administrative report.

Fifthly: The Value We Provide to Companies

• Reducing financial waste in medical insurance.
• Protecting the company from fraudulent or unjustified claims.
• Enhancing the efficiency of insurance management without the need to hire large internal teams.
• Providing accurate and auditable reports.
• Neutral medical decisions led by specialists.

Why Contract With Us?

• Specialized medical and administrative expertise.
• Complete independence from service providers.
• A clear, scalable system suitable for companies and institutions.
• In-depth understanding of the local environment and insurance market.

Sustainability and Cost Reduction! - Smart Pharmacy - An Independent Profit Arm

Project Overview

As part of the medical insurance management system, we propose establishing an independent smart pharmacy that operates with the highest medical and regulatory standards, serving:

• Insured individuals within the approved insurance coverage.
• Non-insured individuals at competitive prices that ensure a direct profit margin.

The pharmacy is managed as a separate investment unit, fully committed to governance and avoiding conflicts of interest.

Why is the Pharmacy an Ideal Complementary Project?

• Continuous demand for medications and pharmaceutical services.
• A ready customer base of insured individuals.
• Daily cash flow from non-insured individuals.
• Higher control over the quality of medication dispensing.
• Reduction of manipulation in drug prices for insurance claims.

Target Categories

1. Insured Individuals

• Dispensing insurance medications according to approved prescriptions.
• Adherence to the insurance ceiling and medical protocols.
• Direct electronic documentation with the claims system.

2. Non-Insured Individuals (General Public)

• Selling medications and medical supplies at market prices.
• OTC products, dietary supplements, medical supplies.
• Additional services (blood pressure, sugar level checks, medication consultations).

Revenue Model

Firstly: The Insured

Payment for medications by insurance companies according to agreements.

Reducing waste by:

• Preventing duplication.
• Adhering to generic alternatives.
• Controlling dispensed quantities.

Profitability here is indirect through reducing claim costs and improving efficiency.

Secondly: The Non-Insured (Direct Profit Source)

• Profit margin from drug sales.
• Profits from non-insured products.
• Paid pharmaceutical services.
• Monthly package offers for كبار العملاء.

Governance and Conflict of Interest Prevention

To ensure trust with contracting companies:

• Complete administrative and financial separation between:
  • Medical Review Management
  • Pharmacy Management
• Medical coverage decisions do not go through the pharmacy.
• Transparent and announced pricing.
• Independent audit reports.

Added Value for Contracting Companies

• Controlled and clear drug prices.
• Reduction of external pharmacy bills.
• Accurate data on drug consumption.
• Improved experience for the insured.
• One partner for insurance and pharmaceutical management.

Future Expansion

• Pharmacy branches in strategic locations.
• Online pharmacy with delivery.
• Direct integration with insurance companies (API).
• Discount cards for the non-insured.
• Wholesale supply of medical supplies.

Investment Summary

The main project (Insurance Management) = Trust + Happy and Healthy Employees + Continuously Improving Work Quality

The pharmacy = Cash Flow + Direct Profit + Sustainability

Together they form:

An integrated system that ensures cost control, service quality, and continuous profitability.