Dr.Himavan Surampalli BAMS; MBA; CPC
Hyderabad
Summary
High energy focused Medical professional (BAMS) , Certified Medical Coder, MBA’ian with 18 years of experience in Health Claims & Audit, Data analytics, Health Underwriting, Grievance Mgmt, Case Mgmt / Audit Recoveries.
Overview
17
17
years of professional experience
1
1
Certification
Work History
General Manager - Health Claims (Dept)
Magma HDI General Insurance Co Ltd.
Hyderabad
06.2023 - 01.2026
- Vision of Development of in-house claims team (Hyd Hub) as part of Process development.Escorting Health Claims Team (Hyderabad Hub) comprising team of Doctors, Non-medicos.
- Claims Ops pertaining to Bussiness Portfolio handled was of Rs 450 Crores with 1.20 Lac claims on an average per FY.
- During Audit up to 35% cases were targeted for Physical Verification with Insured / Provider.
- The Data sanitization was being achieved Cent% at different levels of Processing including Payment posting stage as well.
- Overseeing Daily TPA activities of Claims Processing, Audit, Grievance, Hospital Networking , Payment postings & Information flow to Regulator (IIB) basis PPHI Guidelines issued by IRDAI
- Process enhancement, Audit of claims processed by TPAs, Minimization of Loss ratios and ACS, initiation of Case management and Re-pricing (Saving costs to Co.)
- Hospital Networking
- Medical Underwriting
- Grievance Management
- Insurance Ombudsman Mgmt
- Key achievements under Claims Processing:
- Rs 25 Lacs Savings in a Single High value claim under Insurance Ombudsman (received appreciation from CEO of the Co. for said claim savings)
- Process enhancement and achieved Cent% accuracy as per PPHI guidelines. Nil claims lacuna identified under Group claims segment during IRDAI Audit for FY 2025-2026. Improved Settlement ratios, Lowered Loss Ratios.
- Key achievements under Audit:
- Savings under Case Mgmt & Re-pricing of Rs 25 Lacs for FY 23-24, Rs 1.10 Crores for FY 24-25 for which achieved Annual Award for Team Achievement Excellence Awards Ceremony 2024.
- For FY 25-26 Q1, Q2 & Q3 we have already achieved Rs 85 Lacs under said category.
- Under Fraud & Insurance Abuse identification as part of Audit have saved Rs 1.20 Crores to the Insurance Co.
- Rs 30 Lacs Recovery done from TPA as part of Audit for Lacuna in Processing.
- As part of Business have always given prominence for Lowering Loss Ratios especially in MSME, Banca channels which were Loss making for the Co.
- Actioned on Policies for Cancellation & De-empanelment of Network providers for Fraud & Insurance Abuse.
- Business Analyst: Instrumental in API integration of GC System with TPA Processing Tools
- Strategical Steps : Recoveries from Stake Holders for Insurance Abuse / Deranged Claims processing / Actionable on Network providers for Identified Fraud. Informing Regulator bodies (like IIB) reg the Lacuna.
- Case Management & Re-repricing (Cost containment)
- Keeping tab on the Loss Ratios for Channel Bussiness (MSME, CSB & Banca Channel ), Due dilligence of MSMEs were made strict in view of Nexus Corporates being enrolled with Low Premiums & Huge LRs, Non existence of Groups / Nexus enrollement as Employees for Insurance purpose.
Chief Manager - Health Claims (Dept) and Medical Underwriting
Iffco-Tokio General Insurance Co Ltd
07.2019 - 06.2023
- Insurance & Medical Underwriting: Heading Team of Reimbursement Claims pertaining to Heath Policies (Group Health, Retail / Individual) of 13 SBUS of A.P and Telangana and Approving Fresh & Renewal of Proposals of Health Policies.
- Claim Ops handled for Bussiness portfolio was close to Rs 200 Crores.
- During Audit up to 30% cases were targeted for Physical Verification with Insured / Provider.
- The Data sanitization was being achieved Cent% at different levels of Processing including Payment posting stage as well.
- Resolving Grievance received from Grievance Cell & Customer Support Team.
- Preparing WS for Cases received from Insurance Ombudsman and IRDA Redressal forums.
- Query Management received from Internal Customers (Sales & Marketing) and External Customers (Insured).
- Key achievements under Claims Processing:
- Attended Hearing for 21 Claims under Ombudsman during Corona Period & Nexus identified, Investigation of claims performed & reported the details of Insurance Abuse to Ombudsman body savings costs of Rs 35 Lacs to the Insurance Co (was awarded with "Lunch with CEO for Best performers" campaign.
- TATs improved & Customer satisfaction recommendations received on Social media (One such Happy customer feedback featured on Insurance Co Linkedin Handle)
- Business Analyst: Had been instrumental in Requirements gathering, Composing business requirements specifications, Handling over requirements to developer / IT Team pertaining to PEGA Software.
- Key achievements under Audit:
- Have identified 25 Policies issued under Nexus (Corona Rakshak - Benefit Health Policies) . The policies were immediately reported for cancellation savings costs of Rs 1 Lac under Premium & Rs 10 Lacs under Claims costs.
- Apart from this Nexus policies identified under MSME segment & forwarded same for Policy cancellation.
- Bussiness Analyst: Have been instrumental in Bussiness requirement gatherings & interaction with PEGA Team for Implementation.
- Strategical steps: Have always tried to minimize the Query % for Group claims enhancing TATs & Claim disposal.
- Eye for detail & have achieved good results oriented savings to the Co.
Senior Manager - Pre-Authorization Team
I SHARE BUSINESS SERVICES PVT LTD (Deputation at GHPL Insurance TPA Ltd)
08.2017 - 06.2019
- Insurance & Medical Underwriting: leading Team of Pre-Authorization Dept. Consisting of Inward, Medical Scrutiny, Audit and Outward Department.
- Auditing of Retail and Corporate Claims.
- Team consists of Medico and Non-Medico processing Doctors.
- Responsible for Strict adherence for compliance with GIPSA package for Public Sector Pre-Auth requests.
- Training of team for minimizing unnecessary query transactions, reducing Query percentile with strategies & planning accord of approval after audit for High value pre-auth requests.
- Performance review monthly wise and taking necessary steps for minimizing unnecessary transactions and process enhancement.
- Sample audit for Denial pre-auth requests.
- Team encouragement and review for attaining daily output of nearly 850 to 900 overall OS Tickets (Transactions of Pre-auth requests).
- Business Analyst: Ilad been instrumental in Requirements gathering, Composing user stories, Preparing high level design diagram, Composing business requirements specifications, Handling over requirements to developer/ IT Team.
- Result was development of Single Currency, Multiple Currency Web pages for Processing team and Development of a software tool. The tool was a success In the Middle East Country.
- Key Achievements under Audit & Claim Procerssing:
- Minimizing Query% in comparison to Market percentage.
- De-emapnelment of Few hospitals which were involved in Nexus
- Case Mgmt & Re-pricing of minimizing costs by enhancing strict adherence to GIPSA Packages
Operations Manager-Claims & Network
Starwell Health Management FZ LLC, Dubai, UAE
Dubai
01.2017 - 08.2017
- Insurance & Provider Networking: Review and Accord pre-authorization requests and Re-imbursement claims, Analysis of Daily inflow and outflow of requests.
- Maintain and review weekly, monthly reports.
- Empanelment of Facilities like Clinics / Medical centers, Pharmacies and Hospitals.
- Tariff analysis, negotiation and execution of contracts.
- Client management (like Brokers and Insurance Co's), Being compliant with DHA guidelines and taking appropriate steps for execution of same.
- Attending DHA meets.
- Key Achievements under Audit & Claim Procerssing:
- Strict adherence to Tariffs, Designing packages for OPD under Cost containment and Data analytics & lowering LRs pertaining to Dubai Taxi Policy.
Manager-Claims & Audit Team (Health Management Team)
Infinite Medtech Solutions Pvt Ltd (Formerly called as Satmed Claim Services Pvt Ltd)
11.2014 - 11.2016
- Insurance: Lead Claims & Audit team which comprises of Pre-Approvals, Direct Billing, Reimbursement, EClaims, Rehabilitation.
- Business Analyst: Had been instrumental in Requirements gathering, Composing user stories, Preparing high level design diagram, Composing business requirements specifications, Handling over requirements to developer / IT Team, Providing Developed functionality demo to the Customer.
- Key Achievements under Audit & Claim Procerssing:
- Strict adherence to Packages , Development of Triggers into Claims portal for auto adjudication & audit under Cost containment.
Deputy Manager - (Health Management Team)
Reliance General Insurance Co Ltd
07.2012 - 07.2014
- Insurance & Medical Underwriting: Lead team of Personal Accident, Critical Illness, Cattle Insurance Claims wherein PAN India Claims were processed.
- Have also exposure in RSBY (Kerala) claims processing & audit at Provider level (RSBY-Rastriya Swasthya Bima Yojana is a Policy issued as Joint venture between State Govt and Central Govt; MOLE-Ministry of Labour & Employment).
- Approving Fresh & Renewal of Proposals of Health Policies.
- Resolving Grievance received from Grievance Cell & Customer Support Team.
- Preparing WS for Cases received from Insurance Ombudsman and IRDA Redressal forums.
- Key Achievements under Audit & Claim Procerssing:
- Under audit few Hospitals from Kerala where Nexus was identified were reported to the Preceding officer (Collector) for RSBY Program munder Mass policies & considerable Savings were achieved under Data Sanitization & Payment postings
- Query Management received from Internal Customers (Sales & Marketing) and External Customers (Insured).
Deputy Manager-International Claims
Global Benefits Group (India) Pvt Ltd
04.2011 - 04.2012
- Insurance: Lead Team of Senior International Claim examiners, Audit of High Dollar Claims which include HCFA Ubs/ Directs / Member Claims / Accident/Third party liability / Student Insurance / Caremark Pharmacy, Cashless Claims authorization as per HIPAA (Health Insurance Portability and accountability Act) Guidelines.
- Organizing and participating in weekly interaction on Tuesday of the developments / claim adjudication/sub-ordinates process with the Corporate Office team with CFO, Compliance Manager, Internal Auditors - team of Five members at California.
- Business Analyst: Had been instrumental in Requirements gathering, Composing user stories, Preparing high level design diagram, Composing business requirements specifications, Handling over requirements to developer / IT Team.
- Key Achievements under Audit & Claim Procerssing:
- Result was development of software tool named 'Archer'. The tool was very much helpful for the processing team to create Past medical history details of patient and same to be made available for Successive claims for process without referring the medical documents from first contract date of the Insured, hence accuracy was maintained in Claims processing.
Customer Service Manager - (Health Management Team)
ICICI Lombard General Insurance Co Ltd
03.2009 - 11.2010
- Insurance & Medical Underwriting: Have worked as Customer Service Manager (Panel Doctor) with ICICI Lombard General Insurance Company, Hyderabad dealt with General Insurance Med claims (Cashless and Re-imbursement).
- Approving Fresh & Renewal of Proposals of Health Policies.
- Resolving Grievance received from Grievance Cell & Customer Support Team.
- Key Achievements under Audit & Claim Procerssing:
- Considerable Savings under Pre-auth processing while strict adherence to Packages which were identified as part of audit during Payment processing. Recoveries from Network hospitals were implemented.
Education
MBA - Marketing
Osmania University
Hyderabad, IN-TS01-2020
B.A.M.S - Bachelor of Ayurvedic Medicine and Surgery
NTR University of Health Sciences
Anantha Lakshmi Govt Ayurveda Medical College01-2009
CPC (ICD-10, CPT, HCPCS) - Certified Professional Medical Coder
American Association of Professional Coders (AAPC)
USA01-2016
Skills
- Claims processing (Cashless & Reimbursement)
- Medical underwriting
- Grievance management
- Audit - Fraud detection / Cost Containment / High value claims / Data analytics / Data Sanitization / Data trends / Minimizing LRs
- Cost containment
- Insurance compliance
- Team leadership
- Performance monitoring
- Process enhancement
- Stakeholder engagement
- Business analysis
- Risk assessment
- Data analysis
- Regulatory reporting
- Operations management
- Strategic planning
- Negotiation - Case Management & Re-pricing
- Business networking
- Professional training delivery
- Business strategy formulation
- Regulatory compliance
Certification
- Epidemics, Pandemics and Outbreaks, University of Pittsburgh, 2020-05-01, Credential ID: 92NG2RCB3935
- LEAD Capability Certification Program from UPGRAD 2024
PASSPORT DETAILS
Z6318802, Validity: 19-01-2032
Accomplishments
- At ICICI Lombard - Have achieved savings of 1.2 Crores (INR) under Case referral for Investigation (Retail/Claims).
- At GBG Have been awarded 'Best Employee for the Month' award for the Month Dec 2011 and March 2012.
- At RGICL - Have achieved savings of 1.38 Crores (INR) under Case Referral for Investigation (PA and CI LOB).
- At GHPL Insurance TPA have minimized Query percentage to 14% when compared to Market percentage of 30%, by frequent Training to Employees and also achieved TATS of Discharge Cases of 30 minutes and Fresh cases up to 1 Hours.
- At Iffco-Tokio General Insurance Co Ltd have achieved savings of Rs 2.4 Crores (INR)Lacs(FY 2019-2023) by identifying Fraud claims with Case referrals to Investigation, also have saved costs of Rs 25 Lacs under Insurance Ombudsman cases referral.
- For 4 years Have been given rating of "A / 1" which is meant as highest performance exceeding expectations score for achieving TATS of 3 days for Claim settlement which when compared to market settlement for reimbursement claims is 15 to 30 days and for Grievance management and Customer support.
- Nominated as Best Employee for Q1 (FY 2021-22) for Meet & Great Program with CEO from Customer Service Centre (CSC) Hyderabad.
- At Magma General Insurance Ltd Annual Award for Team Achievement under Case Mgmt & Re-pricing for securing Rs 1.10 Crores savings @Excellence Awards Ceremony 2024.
Languages
English
Proficient
C2
Hindi
Proficient
C2
Telugu
Proficient
C2
French
Intermediate
B1
Hobbies and interests
- Painting (Received award from NMA - National Medical Association for Best Painting during 2002)
- Playing Cricket
- Singing
Family Details
- Mother : Smt.S.Andalu (Home Maker)
- Spouse: Smt.S.Dhanalakshmi (M.Sc Biotechnology - Clinical Research Analyst)
- Kids: Master Sai Shanmukha.S (Studying in 5th Class) & Baby Devanshi.S (Studying in 1st Class)
Timeline
General Manager - Health Claims (Dept)
Magma HDI General Insurance Co Ltd.
06.2023 - 01.2026
Chief Manager - Health Claims (Dept) and Medical Underwriting
Iffco-Tokio General Insurance Co Ltd
07.2019 - 06.2023
Senior Manager - Pre-Authorization Team
I SHARE BUSINESS SERVICES PVT LTD (Deputation at GHPL Insurance TPA Ltd)
08.2017 - 06.2019
Operations Manager-Claims & Network
Starwell Health Management FZ LLC, Dubai, UAE
01.2017 - 08.2017
Manager-Claims & Audit Team (Health Management Team)
Infinite Medtech Solutions Pvt Ltd (Formerly called as Satmed Claim Services Pvt Ltd)
11.2014 - 11.2016
Deputy Manager - (Health Management Team)
Reliance General Insurance Co Ltd
07.2012 - 07.2014
Deputy Manager-International Claims
Global Benefits Group (India) Pvt Ltd
04.2011 - 04.2012
Customer Service Manager - (Health Management Team)
ICICI Lombard General Insurance Co Ltd
03.2009 - 11.2010
MBA - Marketing
Osmania University
B.A.M.S - Bachelor of Ayurvedic Medicine and Surgery
NTR University of Health Sciences
CPC (ICD-10, CPT, HCPCS) - Certified Professional Medical Coder
American Association of Professional Coders (AAPC)