Our platform cuts claim adjudication time by 50%

This article was first published in Mint on 24th July.

 

Photo: Hemant Mishra/Mint

For health insurance to be truly cashless, it’s important that hospitals and insurers talk to each other in real time. Remedinet Technologies Pvt. Ltd is a cloud-based platform that aims to simplify the back-end of cashless claims by connecting hospitals to the insurers. Munish Daga, chief executive officer of the company, spoke to Mint and explained how the platform reduces the turn-around time on claims settlement.

How does your platform expedite the coordination between hospitals and insurers? Do you have to integrate with the systems of both the insurer and the hospital?

Our cloud-based platform talks to the hospital information systems (HIS) on the hospital side and to the insurer’s system on the payer side. So, the data that is entered by the hospital directly flows into the payer system, and not as scanned images over emails, as is the practice now.

There are two models in which we integrate with the hospitals. The first is that we integrate with their HIS. In this, the hospital would enter the data the way it does now, and we convert that into a standard machine-readable format, and send it directly to the insurer’s system.

In the second model, the hospital logs in to our portal and enters the information there by choosing from the drop down menu on various billing items like room type, ailment, line of treatment and pharmacy. We then convert this into a standardised billing format, as prescribed by the insurance regulator, and send the bill to the insurer in a machine readable format.

Yes, we need to integrate with both otherwise the insurer will not benefit from machine-readable bills directly flowing in to its systems. It will continue to get the bills and other documents in the PDF over email. Also, the minute we are integrated with the insurer, or the third-party administrator (TPA) who is the front-desk of the insurer, we can pull out all the records of the policyholder, which the hospital can use to fill up the claim forms.

Currently, we have tied-up with four insurers. These are: Bajaj Allianz General Insurance Co. Ltd, Max Bupa Health Insurance Co. Ltd, HDFC Ergo General Insurance Co. Ltd, and Star Health and Allied Insurance Co. Ltd. We have also tied up with two TPAs: Medi Assist India TPA Pvt. Ltd and UnitedHealthcare Parekh TPA Pvt. Ltd. Between them, they manage claims for all the four public sector undertaking insurers. We have also tied up with 250 hospitals and are in various stages of integration.

How does your platform reduce the turnaround time (TAT) for pre-authorised health insurance claims?

When a patient walks in, the first thing the insurance desk at the hospital asks for is the health card, which has the policy details. If the insurer, or its TPA, is integrated with us, we will directly pull out all the information pertaining to the policyholder from the system, to pre-fill the basic details.

Subsequently, this data pops up on the doctor’s system, who will punch in the medical information and then it will pop up again on the hospital’s administration system for billing.

Right now, it is a paper trail, so the form gets filled manually and then is sent to the doctor and then to the administration department and each step can take 1-2 hours.

With our system, the whole process can be completed within 10 minutes.

Other than reducing TAT, we have coded the medical procedures and cost structures. So, as soon as the doctor lists an ailment or a procedure, we convert it into a standard medical code and this information is sent to the insurer. To list the ailment, we follow the international classification of diseases codes (ICD). For medical procedures, we follow the current procedural terminology codes (CPT), which is again an international standard. For billing, we follow an extended version of the Insurance Regulatory and Development Authority of India (Irdai) billing guidelines. Coding standardises billing and reduces human error.

For instance, there are 20 different ways in which a haemoglobin test is reported, and we convert it into one single code. In fact, the insurer can further use these codes to automate many of their processes.

For instance, most policies have a waiting period of 2 years for cataract. So, when a hospital sends a pre-authorisation for a cataract surgery, the insurer can develop its systems to read the code with the policy terms and conditions and reject the claim if it’s made within the first two years.

This process is manual today: somebody reads the name of the procedure to interpret cataract surgery, then looks up the policy’s date of issue to find out the waiting period.

Standardisation helps insurers to respond fast. The whole process of getting pre-authorisation can be done in less than an hour for an integrated insurer.

Also, once the approval is in the hospital’s system, it pops up simultaneously on the insurance desk, the administration department and the doctor.

Has your platform reduced the TAT at the discharge stage?

The biggest challenge from a consumer perspective is the waiting time. On average, customers end up waiting for 4-6 hours for this process. After the doctor gives a go ahead for discharge, the administration department of the hospital generates the bills and other documents and sends the information to the insurer.

This is the most crucial part as the hospital can not discharge the patient unless it hears from the insurer, because depending on how much the insurer agrees to pay, the balance will have to be collected from the patient. This can take about 3-4 hours and can go up to 8 hours.

It takes so long now, because all the information goes as scanned copies in PDF format. Now imagine a person that had stayed for a week, her bill will list over 150 items. The insurer will then have to segregate and tabulate this under different heads and check eligibility. From our system, the same bill goes as an electronic bill. Think of it like an Excel sheet with 150 items, each with a different code. It becomes easier to segregate and calculate the eligibility. We have been able to reduce the TAT on adjudication of claims by 50%.

The financial sector is proactively adopting technology; the insurance industry seems to be catching up only now. Why do you think insurers are unwilling to go paperless?

Insurers are not adopting paperless settlement of claims because the industry is wary of fraud. Insurers want physical signatures so that they know who to hold accountable. So the final settlement still happens only when all the health claims papers go together at the end of the month for settlement.

But we are in talks with insurers and some have taken a positive view. We would start paperless settlement with tier-1 hospitals.

What is your future road map?

Cashless outpatient is what we are working on. For this we plan to integrate with the physicians, pharmacies and diagnostic chains. Here the response will have to be in real time because when a patient walks into a pharmacy, she doesn’t want to wait. In the West, outpatient claims is about 3 to 4 times the inpatient claim.

Whereas in India, outpatient insurance is almost non-existent. But now a lot of foreign insurance partners have shown interest and we are working with some insurers to work out the modalities.

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