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Health Claims Exchange will Create Positive Impact on Indian Healthcare Sector

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The process of settlement of health insurance claimsin India is soon expected to undergo a major change, for good. The Insurance Regulatory and Development Authority of India has joined hands with the National Health Authority of India to set up a Health Claims Exchange. The new process will involve digitisation and standardisation of medical insuranceclaims related paperwork. The technical work is in final stages and ready for imminent rollout. All this started with a judicial push when the Delhi High Court ordered that medical insurance companies should approve cashless treatment within 30-60 minutes.This is because a delay in discharges means fewer medical resources available for other patients.

What does the Current Process Entail?

As of now, the process is rather slow and disparate with multiple points of delay involved. Generally, a patient submits their KYC document to the hospital. Then they get a claim form from the hospital. This form is filled manually and then it needs to be scanned along with any supporting documentation. These scanned copies are then emailed to the insurer, or if a TPA is involved, to the TPA. In some cases, they may upload these to the insurer or aggregator portal. Once the medical insurance company or TPA have this information, they will digitise this data and verify all the forms and paperwork which is then forwarded to the relevant team for manual adjudication.

The current process is very slow and can run for five to six hours. This means that at the time of discharge, the patient needs to spend long hours at the hospital unnecessarily.As a result, another patient waiting in the queue will experience delay in terms of beds becoming available. Similarly, the manual adjudication process that is currently being followed costs INR 500 per claim, which is an avoidable cost. All in all, the National Health Authority has said that the current process is slow, inefficient and full of chaos. In order to improve the situation, things need to change from the ground up. A portal needs to be developed for automating all the existing processes and the adjudication also needs to be automated.

What will the New Process Involve?

The new process with involve the usage of digital KYC process. This will be done through the Ayushman Bharat Health Account (ABHA). ABHA, which is the new system introduced by the government is an opt-in system that gives a unique patient identifier to every person. The identity of the person is verified digitally. This entire system is a consent-based, patient chosen system. The new system will involve a uniform e-claim standard using digital health information in a standard format. This will be used by both government and privatemedical insurance companies. Under the Ayushman Bharat Digital Mission, six documents have already been finalised. Instead of forms being filled by hand, the data will now be collected digitally and uploaded to health exchange portal, which will then be routed to the insurance company or the TPA. On their part, the insurance companies will also automate the process of claims verification and forms submission.

How will Things Change for Everyone?

The new process is expected to bring in a lot of new advantages and benefits for everyone. First, the new process is expected to be significantly faster than the current process. This means improvement in hospital bed turnaround time for everyone. The new process is expected to be much more accurate and well organised too. Plus, it will lead to cost reduction for everyone, including both hospitals and insurance companies. Here is a look at specific details how everyone is expected to benefit from this new system.

• Hospitals currently have limited access to medical background of the person and they primarily rely on whatever the patient tells them at the time of admission and may not go too far back. With quick access to more accurate and longer patient health records, they will be able to provide better care. Plus, there is also the problem of disparate software being used by different companies and hospitals. These software tools may not talk to each other properly, but with standardisation of forms, this will be resolved.

• Insurance companies and TPAs will also benefit a lot from the introduction of a uniform claim submission portal. It will also improve their access to medical history of the person insured, thus improving the overall decision making and claims adjudication. It will also bring down the cases of falsified, spurious or fraudulent claims. They can pass on these benefits to customers in the form of better premium charges for health insurance policy.

• Government and policymakers will also benefit from this change because they will have improved access to medical information at the demographic level. This will allow them to make better decisions in terms of deployment of healthcare assets and infrastructure across the country and make affordable and quality healthcare accessible to more and more people.

Conclusion

All in all, many healthcare experts feel that introduction of this new policy will also make it affordable for smaller healthcare establishments and hospitals to start accepting cashless claims, which will also improve overall healthcare access to the citizens. A new day is about to dawn in the Indian medical insurance sector and it will be bright and beneficial for everyone.

Disclaimer: The above information is for illustrative purpose only. For more details, please refer to policy wordings and prospectus before concluding the sales.

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