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.

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.