Making Cashless Health Insurance Painless

This article was first published in Healthcare Executive.

As India’s first electronic cashless health insurance claims processing network, Remedinet Technologies is making significant efforts in facilitating seamless exchange of data through an end-to-end Payer-Provider Network writes Munish Daga.

Indian healthcare insurance is witnessing a period of phenomenal growth and development. Market forces have compelled this sector to become a lot more customer centric today. Various initiatives are being undertaken to make the health insurance claim settlement process a hassle-free one for the insured. Cashless health insurance, designed specifically to relieve stress for the insured at the critical moment of hospitalization is a noteworthy step in making the claim settlement process simple for consumers.

Challenges of the current process

To avail cashless health insurance services, the insured is required to fill a form furnishing the details required by the hospitals. This form is shared with TPAs/insurance companies, who, depending on the terms of policy, will share the limit of expenses covered under the policy and accordingly issue an authorization or denial letter to the hospital. At the time of discharge, TPAs/Insurance companies process the claims based on the documents finally submitted by the hospital to the TPA / insurance company. The patient does not need to submit any other document except his policy / membership card.

Heavy reliance on manual processes for gathering information, maintaining records and sharing data in the cashless health insurance claim settlement process often leads to unnecessary delays and inaccuracies, thereby, making it cumbersome for all involved. There is a need to address the following issues relating to the current claim settlement process which causes distress for the patients as well as the hospitals.

Multiple Data Conversion: Health insurance adjudication process involves information exchange between hospitals and TPAs/ insurance companies at various stages. This information is usually exchanged through the transfer of forms physically, scanned copies of forms, or by emails and faxes. Most hospitals have some kind of hospital information systems which means that data at the source is in an electronically readable format. However, when this data is submitted to a TPA / insurance company, it is either converted to a PDF or a paper format (or possibly scanned) so that it can be sent across. Once it is received at the TPA / insurance company end, the data is interpreted by a human resource and then keyed in to the IT platforms of the TPA / insurance company. The PDF / paper-based data is converted back to an electronically readable format. This data is processed and the final action is then taken i.e. approval, denial or request for more information. Once this action is taken, again this electronic data is converted to a PDF / paper format and sent across to the hospital. This process continues for multiple cycles as the cashless process goes through various stages. Incorrect data entry at these stages could result in incorrect amounts being approved and also result in a lot of to and fro between the hospital and the TPA / insurance company.

Lack of transparency: Human interpretation of policy rules at various stages leaves room for different analysis of the same information. Reliance on manual process also makes it difficult for the participants to identify the stage at which the claim settlement process is held at any given point of time.

This multiple conversion of data at various points can be eliminated if a technology backbone can enable exchange of all this information in an electronically readable format. It will add greater efficiency to the process and also significantly reduce human error which is bound to happen when there so much conversion of data.

Remedinet Technologies

Human interpretation of policy rules at various stages leaves room for different analysis of the same information.

To make the process accurate, hassle free and paperless for its intended beneficiaries, a strong technology support is required for transferring the entire process of capturing and transmitting data in the claim settlement process electronically. Software solutions and the relevant IT infrastructure support can help in ensuring that the entire cashless claim settlement is smooth.

As India’s first electronic cashless health insurance claims processing network, Remedinet Technologies is making significant efforts in facilitating seamless exchange of data through an end-to-end Payer-Provider Network (PPN).

Screenshot 1
The dashboard of the software displaying claim status
Source: Remedinet
These products electronically capture, transmit and store requisite data for cashless insurance claim settlement.

Remedinet provides a technology backbone to enable hospitals and TPAs / insurance companies to facilitate the entire cashless insurance process in a far more efficient manner in terms of time and cost and bring in accuracy and transparency. Remedinet’s complete range of products caters to the various limitations in the current claim settlement process, enhancing speed, accuracy and transparency. These products electronically capture, transmit and store requisite data for cashless insurance claim settlement. This data is accumulated and processed through the stages of pre-authorization, pre-discharge (final enhancement) and claim submission. The electronic transmission of data between payers and providers reduces the turn-around time, minimizes inaccuracies and enhances profitability.

Pre-Authorization capability provided by the software Source: Remedinet
Pre-Authorization capability provided by the software
Source: Remedinet
With massive numbers, manual claim processes might become the Achilles’ heel of the health care industry.

The Remedinet platform captures the entire information required to accomplish the various stages of the entire cashless process, in an electronically readable format (not PDF or JPEG). The technology can also integrate with the Hospital Information Systems at the hospital end and the TPA / insurance company platforms on the other end. This eliminates the need to convert electronically readable data to a PDF or paper format just for exchange and then re-convert it back to an electronic format by a human keying in the data from a PDF / paper. The platform ensures completeness of data and also has the capability to tap the data from its source thus, reducing the possibility of errors or data loss significantly. The platform has built in rules which enforce information based on the context thus, largely reducing the possibility of submission of incomplete information.

The platform also enables the availability of completely electronic data at the lowest level of granularity to enable the TPA / insurance company to automate large parts of the administrative and adjudication process which is not possible without having structured electronically readable data at the lowest level of granularity. Remedinet also provides tools and engines to enable automation of various parts of the adjudication process at the TPA / Insurance Company.

Screenshot 3
Remedinet helps improve accuracy
Source: Remedinet

Being a real-time online platform the entire process is completely transparent. Each action is time-stamped and the entire chronology of the stages completed in the process is recorded. One does not need to sift through multiple emails or faxes to understand the details of a particular case. At the click of a button, all the information is available in a clear user-friendly readable format. This also eliminates the controversies and miscommunication typical to manual processes.

Benefits of Remedinet solutions

So far, there has been a significant response to Remedinet’s effective management of cashless health insurance claim settlement process from the healthcare industry. A number of well-known hospitals, insurance agencies, TPAs and Government schemes have adopted Remedinet’s platform and have experienced effective results. The benefits include:

  • Speed: Faster claim adjudication process resulted in minimizing the waiting time for patients. Real-time monitoring of claims made it possible for hospitals, TPAs and insurance company to expedite the entire process by identifying the stage at which the process was held
  • Accuracy: Accuracies in maintaining records have improved exponentially as the entire data is electronic, easy to access and captures all relevant information in a single window thus reducing the need for human interpretation
  • Transparency: Automation of data collection and transmission at the hospital end and the ability to use this electronically readable data to automate large parts of the adjudication and administrative process of interpreting the various policy clauses, makes the entire cashless claims process standardized thereby, bringing in more transparency. Delivery of all crucial information to various participants on a real-time basis is assured
  • Reduction in turn-around time: As all claims records are maintained electronically, the time involved in the claim settlement process was reduced drastically for various participants in the claim settlement process
  • Disaster recovery: Complete disaster recovery mechanism to make all the records accessible with minimum downtime
  • Data archive: Archive of treatment history makes it possible for patients to refer to information for further treatment without actually furnishing the report copies
Remedinet helps reduce turn around time  Source : Remedinet
Remedinet helps reduce turn around time
Source : Remedinet

The need for adoption of technology in health insurance was brought about by the magnitude of demands managed by hospitals and insurance companies alike. With massive numbers, manual claim processes might become the Achilles’ heel of the health care industry. To support the growth of the health insurance in India, it is imperative to embrace meaningful technological solutions. A solution to this predicament is Remedinet’s unique proposition.

Remedinet solutions connect the Hospital Information System to the Payer IT systems through technology, thereby, enabling seamless exchange of completely structured data between the different participants of the Health Insurance Ecosystem. By adopting this channel of electronic exchange of data, health care industry in India is inching closer to replicating global best practices.

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