Emerging Health Insurance Sector – A Digital Approach for Tackling Issues and Challenges

This article first appeared in The HealthCare Radius print issue (November 2017). It has been reproduced here for the readership of this blog. 

As state and central governments strive towards making healthcare affordable, Indian healthcare is transitioning to innovate and introduce best practices using technology to provide basic healthcare access to all citizens. The sector is also having the potential to leverage technology to bring in standardization, create efficient delivery systems thus ensuring reach, growth, and profitability. With this approach, technology can be used to address problem areas across various levels of the healthcare delivery process –

The Consumer Problem

As health insurance serves a crucial healthcare need, meeting the policyholder’s expectations in terms of product and service is crucial. The current scenario, however, is far from ideal. To start with, the unavailability of unbiased information while purchasing a policy and lack of awareness about utilization guidelines, cashless policies has crippled the adoption of policies in India. Secondly, once a patient is admitted, the lack of transparency of the health insurance approval and reimbursement process leads to an unsavoury hospital experience. Thirdly, the current process of information exchange between hospitals and payers is also prone to errors, back and forth between insurance desks that result longer turnaround times, where customer service too suffers.

Link the Hospital

The volume and scale at which insurance desks in hospitals process health insurance claims daily itself justify the need for a streamlined and simplified approach to claims processing that ensures a hassle-free experience for the hospital as well as the patient. Common problems faced by hospitals include – long waiting time after the discharge in case of cashless insurance, back and forth between the insurance desk and the payer and answering continuous queries about policy approval status from relatives due to the lack of transparency in the whole process. Additionally, while hospitals are dealing with multiple insurers to process patient claims, the information exchange process is still manual, time consuming and prone to error.

Primary and Secondary Healthcare

Several experts in the industry suggest that going forward, the industry’s agenda must expand its focus to include an outpatient health insurance cover to enable the utilization of primary and secondary healthcare, synonymous to the tertiary services that are currently being provided. Fewer than 2.50 per cent of patients in any given year need hospital-based care, which implies that 97.5 per cent of all conditions would need to be dealt with at the primary-care level. (Mor & Kalita, 2014) Justifiably, there is a need to invest considerably in primary level healthcare within a framework that averts patients from hospital-based care unless required.

Since, the primary and secondary healthcare providers cater a customer base much larger than that of the hospitals, handling traffic on such a large scale would require a network of primary health facilities, that are adequately staffed, skilled and supported along with a reliable logistical support system on a strong technology framework. Certainly, given the challenge and need, upon this day and age, a technological framework that can support such a large volume of transactions for real-time response is one that is completely automated.

Addressing the issues and challenges – The role of technology

The aim must be to develop an active interdependent relationship with technology as opposed to complete dependency. This relationship will serve the needs of all stake-holders, while also improving efficiency, transparency, and delivery of resources. Similarly, across the key challenges and issues elaborated on earlier, digitalization and standardization of practices can bring about significant changes in the claims exchange process:

For the consumer and the hospital:

For a better way of delivering health insurance, a technology framework should be implemented which brings the provider and the payer into a single platform to exchange claims electronically hence enabling quicker processing of claims data. Automation in terms of providing messages and emails about claim status to the policy holder would result in transparency.

From a hospital’s perspective, electronic data gathered from the claims exchange process will help them view monthly transactions, identify trends, and streamline financial data that can be analysed on a large scale.

On a public level, health insurance data can be used to identify healthcare trends – age groups when individuals are being diagnosed with diabetes, frequency of diseases by geography, etc. With relevant data, predictive analysis is a great way to work on solutions that can benefit coming generations.

For outpatient health insurance:

Delivering primary healthcare to consumers without a digitized technology framework is difficult. A patient visiting a physician for fever cannot wait for the payer to approve eligibility and adjudication on email.

A comprehensive healthcare policy linked with a database such as AADHAR can be a way to deliver outpatient schemes. To elaborate on how it would work – the patient walks in to the clinic, produces the ADHAAR ID, the physician enters the ID for eligibility, selects the ailment from a drop-down menu, administers treatment, clicks the button, the amount is deducted from the sum insured. Similarly, the pharmacy and the diagnostic centre can also be linked on this platform where reports are shared digitally, medicines can be ordered through the platform and delivered home.

Technology also opens possibilities such as appointment scheduling, effective grievance redressal, and case record maintenance from the primary care level.  With technology, we have a better chance at reaching out to a larger populace, especially those in need. With technology, we have a better chance at simplification.

What lies ahead?

The health insurance sector should make much more progress towards becoming more electronic based. In an age where financial payments such as income tax returns filings, paying taxes, statutory documents such as Form 16, TDS deduction forms are all paperless, health insurance claim transactions still require a lot of paper. We must work towards enabling a technology platform and standard where this need is reduced significantly if not eliminated. We, as an industry must collaborate to make that happen because without the aggressive adoption of technology, best practices and creation of standards rapid progress is very difficult.

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Karnataka Police Partners with Remedinet Technologies Cashless Health Insurance Claims

Remedinet Technologies, India’s first completely electronic cashless health insurance claims processing network, has been signed on as the technology partner for Karnataka Police’s ‘Arogya Bhagya Yojane (ABY)’ health insurance scheme. Initiated in 2002, this scheme aims at cashless hospitalization under authorization from the department to all serving police personnel, their families, and dependent parents at empaneled hospitals across the state. The scheme is now powered by the Remedinet payer-provider digital network, fully geared towards making this process hassle free for all non-gazetted and gazetted officers.

Remedinet would facilitate capturing and exchange of relevant claim settlement data, in a structured and electronically readable format. This process is currently manual, error prone and time consuming. By eliminating inaccuracies in the data exchange process, Remedinet solutions would make the claim settlement process faster, accurate and hassle free for the end beneficiaries. As the technology partner, Remedinet would enable various participants in the claim settlement process to monitor the progress, thereby bringing in more transparency.

Munish Daga, CEO, Remedinet Technologies said, “Our association with the Karnataka Police for their ‘Arogya Bhagya Yojane’ scheme is indeed a proud moment for us. To make the government healthcare schemes beneficial for the target group, it is imperative to embrace latest technology. Our aim is to bring seamless customer experience through adoption of latest technology in the Indian health insurance sector. The scheme brings convenience and stability to an important section of our civic society and we are happy to contribute our bit in facilitating adoption of latest technology in the Indian health insurance sector. We have grown to cover more than 75000 personnel and have a hospital network of about 150 hospitals. We are confident that our expertise will make us the ideal partner for the Arogya Bhagya Yojane scheme.”

The Remedinet platform has been instrumental in laying the requisite groundwork and making government healthcare schemes beneficial for the target groups in other states. The seamless experience through the stages of pre-authorization, pre-discharge (final approval) and claim submission, aim at reducing the turn-around time and enhancing productivity of various participants in the health insurance claim settlement process.


Revolutionising health insurance with technology

Munish Daga, CEO, Remedinet Technologies, expounds on the scope and possibilities of digital platforms for healthcare insurance in India. This article was first published in the January edition of Express Healthcare.

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The Gap

Despite the technological evolution of the healthcare sector over the past two decades, health insurance in India continues to grapple with the same difficulties such as lack of adoption and complex utilisation. As a result, the adoption numbers struggle to make it past a disappointing percentage figure in a country with the second largest population in the world. On the flip side, the situation in which the health insurance industry currently finds itself, also presents tremendous opportunities to evolve, possibility to scale, and scope to become profitable. The emergency of the situation, in several cases has not only served as a business opportunity, but also led to the adoption of digital frameworks as foundational pillars that ensure last mile delivery of health insurance for the policyholder.

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Pre-intimation can make the hospitalisation experience better

This article was first published in the December 21st issue of HT Mint.

Pradeep Gaur/Mint

Making the adoption and utilisation of health insurance customer-friendly, simple and jargon-free for the policyholder is a continuous process that each industry stakeholder is tackling in its own way.

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Remedinet Technologies

Remedinet was profiled in the August 2016 issue of Insurance Times Magazine

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Have proper paperwork to cover dependant under employer policy

This article was first published in Mint Money.

Shyamal Banerjee/Mint

Shyamal Banerjee/Mint

Health insurance adoption, utilisation, and administration each pose a unique set of challenges for various stakeholders—insurance companies, third-party administrators (TPAs), regulators and government bodies, and hospitals—of the insurance ecosystem. Seamless individual processes and functions from each of the stakeholders that come together cohesively can provide customers with a health insurance cover that they can use without experiencing a financial crisis for the treatment.

Over the last decade or so, corporate group health insurance covers, offered by employers to their employees, has come to form a significant chunk of health insurance penetration in India. Under such a policy, not only is the employee covered, (depending on the policy terms) their dependents such as spouse, children and parents are also covered. The sign up process involves the employee submitting forms that contain the employee’s and her dependents’ details to the human resources (HR) department, which in turn consolidate and send the information to the insurance company or the TPA. Following this, the health insurance policy ID cards are handed over to the employee.

In most cases, corporate policies are cashless health insurance policies, wherein the patient is not required to pay upfront cash and the bill is settled between the hospital and the payer or the TPA (with a small percentage of copayment or exceptions not covered under the policy being borne by the patient). At the hospital, the claim is processed by the hospital TPA desk, which coordinates with the TPA who adjudicates the claims on behalf of the insurer to settle the insurance claim against the bill. Thus, pre-authorisation of the sum payable and patient’s eligibility are processes that rely on the information shared by the patient at the time of sign up.

In the case of a dependent, to utilise the policy, they have to be enrolled as dependents in the TPA systems. In many cases, dependents are not enrolled in the TPA systems even though the relevant forms may have been filled in the beginning. Owing to various reasons including, the use of unstructured communication channels between HR and the insurer or the TPA, this information does not flow to the TPAs. Thus, even though the employee may have filled the forms to include dependents under the employee provided cover, there can be significant delays in receiving the approvals from the TPA leading to avoidable heartburn and stress for the policyholder at the time of availing the treatment.

In such scenarios, the primary policyholder and her dependents using the policy for treatment are likely to face problems such as the ones mentioned below:

Difficulty in enrolment: To get the dependent enrolled with the TPA, the primary policyholder will have to get in touch with all parties involved—the HR team with the employer, the insurance company, and the TPA. Various rounds of back and forth involving calls and e-mails, documentation with each and response time that can go up to several hours derails the treatment and adds to the patient’s woes.

Mounting costs: As a result of the added time (and days) spent in getting the insurance procedure going, along with delays at all stages, the time spent at the hospital can potentially escalate costs or there may be a need to make a deposit to the hospital upfront due to lack of approval from the TPA. This, in turn, can add unnecessary costs to your final bill and become a financial burden that could have otherwise been avoided.

What should the primary policyholder do?

To ensure that the dependents are enrolled in the TPA systems, it is best that the employee follows up with the relevant department and the company’s HR team to get a confirmation regarding this as soon as sign-up is completed.

This will ensure that in the unfortunate situation of a medical need for any of the dependents, precious time is not lost. At the time of crisis, the primary member and her family does not have to go through a bad experience while availing cashless treatment. Taking a few precautions and being prepared for such situations can help policyholders greatly reduce the stress related to availing insurance.

While the health insurance ecosystem gears up to adopt electronic platforms, it is wise for the policyholder to take necessary precautions to ensure that this does not add to the worries and stress at the time of any hospitalisation.

Munish Daga, chief executive officer, Remedinet Technologies Pvt. Ltd.

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Speciality clinics looking to healthtech startups for IT upgrades

This article was first published in the Times of India.

CHENNAI: Hospital chains like the Apollo Group, Manipal, Columbia Asia and Fortiswere among the first in India to invest heavily in IT. Joining their ilk are speciality clinics like Vasan Eyecare, Davita, Narayana Health, HCG and Agwaral Eye Clinic, which now taking to the IT highway and upgrading to ICD10 code compliance, payment-facilitating web portals, creating mobile apps, maintaining electronic health records and booking doctors’ appointments.

Startups like Remedinet, S10 Healthcare, Medi Assist are coming to the rescue of such speciality clinics for cancer, cardiac, dental and eye care. Medi Assist, which recently invested $1 million in Goa-based mobile fitness venture MobieFit, has come up with MediBuddy, a mobile app for hospitals and specialty clinics. The mobile app allows policyholders to raise and track claims, plan an e-cashless hospitalization, search networked/empanelled hospitals, book wellness services, buy drugs and maintain electronic health records. “We also have e-cashless, which helps users book cashless admission at a network hospital using their smartphones. You can choose the room type, get an idea as to projected bill, cost of treatment, and cut out waiting time for hospital admission,” said Prashant Jhaveri, head, products and strategy, Medi Assist Healthcare Services, which also has a MediBuddy web portal for access to health benefits.

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