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.
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.
This article first appeared on India Infoline.
While we all hope and pray to enjoy a healthy, long life, medical care is something we do require at some point in our life. The unpredictable, unforeseen medical expenses can mean extra financial burden in this day and age. Having a health insurance is best way to cut down these expenses. A health insurance covers these charges and provides you with risk coverage against unpredictable medical emergencies. Hence, it is crucial that you choose the best health insurance plan for you and your family.
You will never know if you do not ask! To select the most suitable health insurance policy, it is essential to understand the fine prints of your policy and get clarity on factors that really matters while a selecting the best option. Here is a list of 7 things which you should discuss with your insurance agents before taking the plunge:
- Does your insurance company offer cashless hospitalization?
Most of the health insurance companies offer special schemes and plans which suit your individual healthcare requirements. As per Insurance Regulatory and Development Authority (IRDA) guidelines, if your insurance company has tie-ups with hospitals (Network hospitals) then you do not have to pay for taking treatments in those hospitals. This policy is called ‘Cashless Hospitalization.’ The expenses under this policy are settled directly between hospital and health insurance company with the help of a Third Party Administrator (TPAs) and does not require your involvement .Ask your insurance company if they facilitate cashless health insurance policy or not.
This article first appeared on Moneycontrol.com.
An unforeseen medical emergency can mean an unexpected financial burden apart from the emotional stress that such an incident entails. To ensure that adequate financial resources are at our disposal during such emergencies, we sign up for a health insurance policy. However, while this measure affords us some peace of mind, the family of the patient is still required to fill in a plethora of forms and furnish initial amount at the time of hospitalization. Though this amount can be claimed later from the insurance companies, arranging the required some at such an hour could be quiet challenging, especially if the procedures are long and complicated. Cashless health insurance policies are designed specifically to relieve stress for the insured at the crucial moment of hospitalization.
Cashless health insurance
Cashless health insurance is a policy where the health insurance companies settle the hospitalization and treatment bills directly with the hospitals without the immediate involvement of the insured. Under cashless health insurance scheme, Third-Party Administrators (TPAs) act as the bridge between the insurance companies and the hospitals. All the medical bills raised by hospitals are sent across to TPAs who then coordinate with the insurance companies to settle the claim. This process eliminates the need to furnish any amount at the time of hospitalization and also minimizes documentation required to avail medical services.
Cashless mediclaim service can be of two types:
- Planned claim – When the insured is aware of the hospitalization in advance
- Emergency claim – When immediate hospitalization is required due to serious illness or an accident