National Health Insurance Scheme Operations

Overview:

Introduction:

National Health Insurance Schemes (NHIS) are government-regulated programs designed to provide affordable and equitable healthcare coverage by pooling financial resources and managing healthcare costs. These schemes ensure access to medical services while maintaining financial sustainability through structured contributions and reimbursement mechanisms. Effective NHIS operations require deep khnowledge on policy frameworks, claims processing, risk assessment, and service provider coordination. This training program provides participants with advanced insights into NHIS operations, tailored specifically to the Saudi healthcare system, ensuring compliance with national regulations and enhancing efficiency in health insurance administration.

Program Objectives:

By the end of this program, participants will be able to:

• Analyze the regulatory and policy framework of NHIS within the Saudi healthcare system.

• Evaluate strategies for optimizing claims processing and fraud prevention.

• Assess risk management approaches for sustainable health insurance operations.

• Develop strategies for improving provider network management and cost control.

• Perform quality assurance measures to enhance service delivery and patient satisfaction.

Targeted Audience:

• Health insurance professionals and policymakers.

• Healthcare administrators and hospital managers.

• Risk and compliance officers in the health sector.

• Financial analysts specializing in healthcare economics.

• Professionals involved in regulatory oversight and healthcare quality management.

Program Outline:

Unit 1:

Foundations of National Health Insurance Schemes:

• Definition and objectives of NHIS.

• NHIS models and global practices.

• Legal and regulatory frameworks governing NHIS in Saudi Arabia.

• Financing mechanisms and risk pooling strategies.

• The role of government agencies and private insurers in NHIS.

Unit 2:

Health Insurance Claims Processing and Fraud Prevention:

• Key steps in claims processing based on Saudi NHIS policies and CHI regulations.

• Common fraud schemes in Saudi healthcare insurance and their financial impact.

• Fraud detection techniques and preventive measures under Saudi regulatory frameworks.

• Role of artificial intelligence in claims auditing for Saudi insurers.

Unit 3:

Risk Management and Cost Control in NHIS:

• Key activities for identifying and mitigating financial risks in Saudi NHIS operations.

• How to manage high-cost treatments and chronic disease coverage within Saudi NHIS.

• Cost-sharing models and their impact on healthcare utilization in Saudi Arabia.

• Strategies for balancing affordability and financial sustainability under Saudi healthcare policies.

Unit 4:

Provider Network Management and Service Coordination:

• Key activities involved in the process of establishing and maintaining provider contracts based on CHI standards.

• Reimbursement models used in Saudi NHIS and their effects on healthcare quality.

• Performance evaluation tools and provider benchmarking according to Saudi accreditation requirements.

• How to address disputes between insurers and healthcare providers in Saudi Arabia.

• Frameworks for enhancing patient experience through seamless service delivery under Saudi NHIS.

Unit 5:

Quality Assurance and Regulatory Compliance in NHIS:

• Importance of healthcare quality metrics specific to Saudi NHIS.

• Regulatory standards and accreditation requirements in Saudi Arabia, including CHI guidelines.

• Tools for monitoring and evaluation of NHIS performance within the Saudi healthcare system.

• Strategies for continuous improvement in service delivery aligned with Saudi Vision 2030 healthcare reforms.

• Future trends and innovations in Saudi national health insurance.