A Health Claims Exchange Is In The Making To Speed Up Cashless Claims

Soon, settling health claims may become faster, allowing swifter discharge of patients from hospitals.

The National Health Authority and the Insurance Regulatory Development Authority of India are exploring setting up a health claims exchange that will help digitise and standardise claims forms, according to an internal document reviewed by BQ Prime.

"The platform is ready to be rolled out in the next few weeks," Dr. S Prakash, managing director, Star Health and Allied Insurance, told BQ Prime.

This comes after the Delhi High Court's April 2021 judgment during the Covid-19 pandemic. The court had asked insurers to approve cashless treatment within 30-60 minutes as a delay in discharging patients was delaying admission to those needed immediate medical attention.

"We are happy that this idea is finally coming to life,” Bhabatosh Mishra, director underwriting, products and claims at Niva Bupa Health Insurance, told BQ Prime. "The idea was discussed in the General Insurance Council for a while now, where stakeholders had identified the need for a common and standard information exchange portal for faster claim resolution."

Emailed queries to the NHA and IRDAI remained unanswered.

Current Process

• The patient submits know-your-client document to the hospital.

• The hospital provides a claim forms that needs to be filled by hand and requires scanning of supporting documents. These are emailed for pre-authorisation to the insurer or the third-party aggregator.

  Or the hospital downloads/prints data from the health management information system and uploads it to the portal of the insurer or the aggregator.

• The insurance company digitises/verifies the forms before manually adjudicating the claim.

The process takes almost five to six hours, making patients wait before being discharged. And that puts pressure on hospital infrastructure due to delay in vacating beds.

The National Health Authority identified that the hospitals are required to deal with over 30 insurers and aggregators, along with tracking and reconciliation. It also costs Rs 500 per claim to adjudicate it manually, the health authority said, terming the process "chaotic, slow, and inefficient".

The insurance regulator along with the authority proposed a portal for automating the existing process as well as for auto-adjudication of claims. It includes a common digital format for claims across all insurance players, government and private. The proposal is to create one or more health claim exchanges serving as a public digital infrastructure to process claims.

The plan aims to "reduce cost per claim, better data on service level agreements for various processes like time to pre-authorise/discharge," said the National Health Authority's document.

Proposed Process

• The hospital will obtain a digital KYC with Ayushman Bharat Health Account through Health Management Information System. The ABHA is a patient identifier which grants a unique digitally verified identity to a person and consent-based access to health records.

• The second step will be a common e-claim standard across both government and private insurers and obtaining digital health records in structured format. Six documents for this have been finalised by Ayushman Bharat Digital Mission.

• This data will be uploaded on the health exchange portal, which will be routed to the insurer or the aggregator.

• The insurer will then be able to use automated technology to verify claims or submitted forms.

According to the authority, the new process will help policyholders and hospitals to track claim status and enable automatic transfer of payments. It will also help in checking fraud.

The initiative is expected to resolve:

• For Insurers and TPAs: Lack of a unified platform for claim submission, limited or no access to patient's medical history and limited fraud analytics.

• Hospitals: Limited access to medical history of patients, large volumne of medical records, different softwares for multiple insurers or aggregators, and poor efficiency in claim management.

• Policymakers: Insufficient information about diseases that can be prevented and limited monitoring and analytics.

"Health claims exchange is the first step towards streamlining the health insurance claim process," Star Health's Dr. Prakash said.

This, he said, will enable hospitals to reach multiple insurers through one portal. "We will be moving to a one-to-many approach from a many-to-many approach. This will help bring standardization to the entire ecosystem."

According to Mishra, this exchange would be able to provide aggregated information for analysis of health and cost trends. It could also add value by reducing instances of fraud and abuse.

The new platform will do away with the hospital's need of having to log into multiple insurer websites for addressing different claims, Mishra said. "Insurers will be able to auto-adjudicate claims easily as all hospitals will upload data in a standard format."

This standardised data exchange protocol, he said, will be able to integrate with the health management information system and pull out relevant details to process claims without the need of a highly developed software.

Currently, customers with multiple policies have to manually approach their other insurer for reimbursement once the claim exceeds the limit of one policy. The proposed exchange will have information related to all policies, easing the process, Mishra said.

While the cashless facility is available only for network hospitals of the insurer or third-party aggregators, Mishra said the common portal will make onboarding of more hospitals to their network easier.

Dr. Prakash said in the past, some hospitals were hesitant to become empanelled due to the documentation involved which varies from insurer to insurer. This move will make the process simpler which will encourage more hospitals to get empanelled. This will also bring in more transparency in practices. So all in all, this is a good move for insurers, hospitals and especially customers.