Page 29 - The Insurance Times August 2024

There are dispute related to billing where the hospitals ask personal capturing data are to be enforced effectively to
for authorization on the basis of information provided during make the data reliable for proper interpretation, predictions
admission and the actual diagnosis/treatment is totally of morbidity and pricing of products.
different. Lack of knowledge and understanding about
insurance policy wordings/requirements creates many Recent initiatives by the General
disputes on payments.
Insurance Council and IRDAI - Challenge
c) Cashless service at an enhanced cost to the for the claims servicing
customers Cashless Everywhere
The Insurers charge extra premium from the customers for The "cashless everywhere" initiative was launched
cashless services. When claims is a post sale service provided January,2024 by the General Insurance council has
by the Insurers, it is unethical on the part of the insurers to facilitated the patients with health insurance coverage to
charge a separate fee for cashless service . The TPAs are avail treatment even at any non-network hospital besides
paid by the insurer for the services on a fee or remuneration the network hospital on cashless basis anywhere in the
basis. If the services are a part of the insurance contract, it country. This Cashless Everywhere is subject to:
should be made available to all the customers and the cost a. Intimation to be received at least 48 hours prior to the
for this post sale service needs to be incorporated in the admission by Insurers for planned hospitalisation.
premium cost itself.
b. Intimation to the Insurance Company within 48 hours
of admission for emergency treatment.
d) Cost escalation by the providers
c. The claim should be admissible as per the terms of the
Originally TPAs were required to rationalize the cost of
treatment. But the reality is altogether different. The policy and the cashless facility should be admissible as
negotiated rates for various procedures and diagnosis are per the operating guidelines of the Insurance Company.
often on higher side for the insured customers. Thus, are
working contrary to the role assigned to them and lack The initiative is though a great facility to the customers
professional ethics. but there may be many practical challenges for the Insurers
and TPAs. In cases of disparity in the rates being charged by
the Providers and the reimbursement rates of the
As there is no regulatory body of healthcare providers, the
hospital industry does not self-regulate itself. Several Insurers, the patient might have to pay the difference
malpractices have crept into the system, instances of out of pocket leading to their grievances. Unless the
charging high prices, medical negligence, over treatment Providers are regulated and rates charged are standardised
to inflate bills, unnecessary tests are the ethical issues which at, implementation of Cashless facility in Non-
are on rise and impacting the health of the health insurance Network hospitals is going to be a tough task for TPAs and
system. These need to be checked by the TPA while Isurers.
negotiating with the provider. Cost containment of providers
is a major challange for the TPAs and Insurers. A closer look IRDAI new norms for health Insurance
into the intricacies of medical treatment on the part of TPA claims servicing
when the patient is hospitalised could save the Insurers IRDAI recently issued a Master Circular on Health Insurance
pocket from inflated claims.
Business specifies following major servicing rules for the
Insurers :
e) Improper data capturing by TPAs
a. Every insurer to achieve 100% cashless claim settlement
TPAs generate lot of valuable and comparable data on in a time bound manner and to go for reimbursement
utilisation of services and their cost structures. Incomplete
of claims only in exceptional circumstances.
and improper data capturing makes future estimates
difficult. Capturing of proper diagnostic codes at the TPAs b. Decision on the request for cashless authorization to
office is essential for analysis and predicting future trends. be taken immediately in one hour from the receipt of
Only 66% of input claim data has valid diagnostic codes in request. Necessary systems and procedures are
the data analyses report of Insurance information Bureau required to be put in place by the Insurer immediately
report 2019-2020. Strict regulations, proper implementation and not later than 31st July, 2024.
of the standardisation initiatives with proper training of the c. Insurers to arrange for dedicated Help Desks in physical

The Insurance Times August 2024 27