Page 242 - IC38 GENERAL INSURANCE

1. The documentary evidence of the illness
2. Treatment provided
3. In-patient duration
4. Investigation Reports
5. Payment made to the hospital
6. Further advice for treatment
7. Payment proofs for implants etc.

Verification of documents follows a checklist which the claim processor
checks out. Most of the companies ensure that such checklists are part of
the processing documentation.

The missing documentation is noted at this stage – while some processes
involve requesting for the documents not submitted by the customer /
hospital at this point, most of the companies first complete the scrutiny of
all the documents submitted before requesting for additional information so
that the customer is not inconvenienced.

d) Capturing the billing information

Billing is an important part of the claim processing cycle. Typical health
insurance policies provide for indemnifying expenses incurred in the
treatment with specific limits under various heads. The standard practice is
to classify the treatment charges into:

 Room, board and nursing expenses including registration and service
charges.

 Charges for ICU and any intensive care operations.
 Operation theatre charges, anaesthesia, blood, oxygen, operation

theatre charges, surgical appliances, medicines and drugs, diagnostic
materials and X-ray, dialysis, chemotherapy, radiotherapy, cost of
pacemaker, artificial limbs and any medical expenses incurred which is
integral part of the operation.
 Surgeon, anaesthetist, medical practitioner, consultant's, specialists
fees.
 Ambulance charges.
 Investigation charges covering blood test, X-ray, scans, etc.
 Medicines and drugs.

Documents submitted by the customer are examined to capture information
under these heads so that the settlement of claims can be done with
accuracy.

Though there are efforts being made to standardize the billing pattern of
hospitals, it is common for each hospital to use a different method for
billing and the challenges faced in this are:

 Room charges can include some non-payables such as service charges
or diet.

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