scorecardresearchMedical Insurance: This is how delays in approving claims can be avoided

Medical Insurance: This is how delays in approving claims can be avoided

Updated: 09 Aug 2022, 10:52 AM IST
TL;DR.
Hospitals have an in-house claims settlement department that speeds up the coordination with Third Party Administrators or TPAs. TPAs are outsourced agencies that have been given the authority by the insurance company to sanction claims on their behalf.
Health insurance is a contract between the insured and the insurance provider that guarantees you financial protection in the event of a medical emergency.

Health insurance is a contract between the insured and the insurance provider that guarantees you financial protection in the event of a medical emergency.

There are instances in health insurance, where a policyholder has decided to opt for the “cashless” claims process, hoping for a quick discharge from their treatment or procedure, only to end up facing some delay in their discharge, defeating the swiftness that was anticipated when choosing the “cashless” route.

The “Byzantine” process is known to intimidate even the most meticulous policyholder. To improve their service, hospitals have an in-house claims settlement department that speeds up the coordination with Third Party Administrators or TPAs. TPAs are outsourced agencies that have been given the authority by the insurance company to sanction claims on their behalf.

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Before admission

It is a prerequisite for a policyholder who wishes to raise a claim against their health insurance to get pre-approval from the insurer at least 48 hours before the date of admission. This will require sharing information on the policyholder’s desired hospital, the date of their surgery, along with submission of tests, scans, and the doctor’s prognosis.

The TPAs, who are authorised by the insurer, after receiving all relevant documents and information, authorise the claim by checking its pre-authorization requirement. Upon approval, the TPA releases an initial amount to the hospital. The TPA then reaches out to the hospital, informing them of the authorisation of the claim, preparing the hospital for the new admission  

The discharge process in the hospital

An important parameter, when judging the efficiency of a hospital’s administration is the discharge process Turn Around Time (TAT). Upon completion of treatment, and the attending doctor’s approval, the process of discharge of a patient begins. This is when the hospital begins to prepare the “discharge summary”, a crucial document that is required for the claims process. The time taken in the preparation of the discharge summary varies across hospitals. The major variables influencing it are:

  • The number of medical transcriptionists working in the hospital
  • The number of patients discharged from the hospital at any given moment
  • Time is taken for approval by the attending doctor

When doctors review the discharge summary, there may be corrections. To address these corrections, the summary would have to go back to the medical transcriptionists. Once corrected, the doctor reviews the document again before signing their countenance to the summary. This constant back and forth is known to cause delays. Only after the doctor’s signature does the summary reach the hospital’s claims settlement department. After the discharge summary, the hospital prepares the bill for its services. Delay in preparation of the bill and submit it for claims contributes to the protraction of TAT.

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Coordination between hospitals and TPAs

Inspecting the accuracy of a claim requires constant back-and-forth between the in-house claims settlement department and the TPA. The hospital’s claims settlement department is responsible for furnishing all the documents germane to a policyholder’s treatment. They are also required to answer queries raised by the TPA over the hospital’s administrative day-to-day terminologies that are transcribed in the policyholder’s file. The efficiency in the processing of claims depends largely on the swiftness with which these queries are resolved.

Costs associated with the delay

The delay caused by the claims process can result in the policyholder spending more time in the hospital than is necessary, blocking a bed that could be used to care for another patient who is in need. Poor bed management is known to impact the profitability of hospitals and call into question the efficiency of their service. The extra time spent in the hospital implies that the insurer will also have a larger claim to settle than anticipated. For the policyholder, more time spent in the hospital implies more costs associated with food and certain services that are not covered by a health insurance policy.

Employing technology to improve administrative efficiencies

Delays in discharge hold financial liability for all the stakeholders (hospital, insurer, policyholder). It is therefore critical that hospital administration and TPAs develop mutually agreeable strategies to reduce the time it takes to process a claim. Studies across the world have shown that administrative inefficiencies are the sole contributors to delays in discharge.

With the evolution of AI (Artificial Intelligence), technology can be deployed to automate and speed up many administrative processes, such as the preparation of discharge summaries or the billing process. Inspiration can be drawn from the United Kingdom’s NHS (National Health Service), where a growing number of hospitals are using the ‘Electronic Discharge System’ platform.

This system auto-completes patient discharge summaries with information from drug charts and case notes. This system also recommends appropriate medication and dosages and transmits the discharge summary to the attending physician for their perusal.

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What can policyholders do?

While the delays in discharge are largely due to administrative inefficiencies, policyholders are expected to know the terms and conditions associated with their policy, specifically the treatments that their policy covers. A good rule for policyholders is to always seek treatment in empanelled hospitals to ensure they receive adequate coverage and timely discharge.

Policyholders are also expected to keep all documents pertaining to their policy to gain quick approval for their treatment before admission. Communicating the discharge approval directly with the TPA is a good measure to enable a smooth discharge process during emergencies when accessing policy documents immediately may not be possible, the policyholder is expected to communicate their predicament to their insurance agent/broker, so that the insurance broker can provide the hospital with the necessary information regarding the policy.

Satish Gidugu is the Chief Executive Officer of Medi Assist

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First Published: 09 Aug 2022, 10:52 AM IST