Insurance – Solutions for health insurers

“Private health insurance is at a turning point. The Covid-19 pandemic is intensifying the pressure. It remains to be seen which insurers can meet customers’ requirements to become long-term partners at their side in all health matters.”
Mirko Theine, Senior Manager, zeb





Private health insurance is undergoing a transformation. There are two main drivers for the changes that are taking place: firstly, digitalization with its new opportunities for interaction between all stakeholders in the healthcare system; secondly, further increasing cost pressure due to the prolonged period of low interest rates as well as rising expenses resulting from advances in medical technology and new treatment methods. Last but not least, digitalization requires high investments in medical-technological infrastructure, such as the Gematik connection of private health insurers and related initiatives, e.g. the electronic patient record (ePA) and e-prescriptions, as well as further automation using artificial intelligence (AI) or robotics.


More and more providers no longer wish to be viewed merely as companies that refund costs, but rather as full service providers on all topics relating to their customers’ health. The customer and their needs are becoming the focus of health insurers. At the same time, a paradigm shift in the health behavior of customers can be observed. Patients no longer want to be reactive and passive in the face of illness, but increasingly proactive, taking preventive measures. Health continues to gain importance – it is literally consumed to prevent any illness that could arise. Medicine and health are becoming a lifestyle.

As a provider of comprehensive healthcare services, private health insurers stand at their customers’ side in any given situation – in sickness, recovery and maintaining health. This offers great opportunities – new touch points are opening up.

Solutions & fields of action

Development into a healthcare provider

To ensure that the transformation from a reimbursing function to a healthcare service providing function succeeds, insurers must position themselves clearly in the healthcare services market. An overall view of the provider market enables the selection of appropriate available healthcare services. In addition to the service itself, it is important to select the ideal service provider and weigh make-or-buy decisions. As a result, the health insurer gradually creates an individual ecosystem for health.

The decisive factor in this context is not the number of health services, but their targeted use and proper steering in health management. Benefit controlling forms the basis for ensuring desired effects and enables ongoing adjustments and iteration in the range of services. 

Benefit management of the future

When strategically setting up benefit management, it is important to develop a holistic view of all its components. Key elements are the factory for claims processing and reimbursement as well as health management. They impact both organization and personnel. IT systems and workflow management enable functioning processes. The holistic approach allows insurers to align the individual components while taking interactions into account. In the factory for claims processing and reimbursement the focus is on the further expansion of automated processing, whereas requirements for health management are primarily posed by the stronger networking of market players and an increase in cooperations and services offered. 

These developments require a transformation in organization and personnel. The previous focus of manual processing is being shifted to managing customers in interconnected health management. This requires a cultural change that affects the entire insurance organization. 

Process automation in the health factory 

In order to meet customer requirements for real-time reimbursement, further development towards a comprehensive factory is necessary. Naturally, the focus is on the further automation of processes and the expansion of automated processing of claims. In the target picture, only clearly defined special fields are then outsourced to subject matter experts in the review department, in some cases also with the involvement of external service providers. 

The factory is based, on the one hand, on the selection of suitable (standard) software or software modules and their smooth organizational use, and on the other on process flows designed to meet the new challenges. By means of customer-centric process analyses via the “process journey” approach, insurers can identify selective improvements and application potential for Robotic Process Automation (RPA) and derive structural fields of action in a targeted manner.

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