Health insurance claim reform: Cashless treatment at any hospital may be a reality next year

Often health insurance policyholders have to go for urgent treatment to a hospital that is outside the network hospitals due to the cashless facility offered by their insurers. In such cases, they have to pay the full amount of treatment and then go through the cumbersome claim process for reimbursement.

To ease the hassles faced by health insurance policyholders, the Insurance Regulatory and Development Authority of India (IRDAI) is likely to introduce a 100% cashless hospital network, including listed and unlisted hospitals, two key players in the industry told ET Wealth Online. -Both the listed hospitals will be included. , Therefore, health insurance policyholders can soon avail cashless treatment at hospitals, even if they are not empaneled with their insurance companies. What does this mean for you and how will it help you? Read here to know.

Cashless hospitalization under health insurance: What are the current rules?
As of now, a health insurance policyholder can avail the cashless facility only in those network hospitals with which the insurance company has tied up. The insurance company settles the medical expenses directly with the network hospital, thus, policyholders get the benefit of getting medical treatment without worrying about sudden outflow of funds due to medical expenses.

Each insurance company has an independent network of medical service providers with which they have tie-ups. At present, cashless settlement facility is available in only 49 percent hospitals in India. “Although this network includes all major tertiary care hospitals, the spread of the network of hospitals was dependent on the density of customers in a particular geography. Therefore, there will certainly be some customers seeking treatment in hospitals for which their insurer has no tie-up. An executive at one of the leading insurance companies told ET Wealth Online on condition of anonymity.

100% Cashless Network: Cashless facility in unempanelled hospitals – What is going to change?
The insurance regulator has proposed to launch a 100% cashless network in collaboration with the General Insurance Council (GIC). “In the process of doing this, the regulator may consider cashless treatment even from unlisted hospitals,” says Parthanil Ghosh, president, retail business, HDFC ERGO General Insurance Company Ltd.

Another health insurer said the proposed initiative would merge the networks of all insurers creating a master network that could be used by all participating insurers across the industry.

Cashless hospitalization in unempanelled hospitals: How will it work?
How can you get cashless facility in a non-empanelled hospital? Health insurers said that for treatment in an unempanelled hospital, the health insurance policyholder has to inform the claim well in advance of hospitalization (about two days in advance), so that the insurance company can initiate coordination with hospitals for cashless treatment. Charges will be based on the existing listed insurers’ rates. “Since a significant portion of reimbursement claims are due to the insurance company being unaware of the admission, this will be an important factor for successful implementation,” the health insurer said.

Adding to this, Ghosh says, “Under an integrated cashless network concept, the existing cashless network of different insurers can be used by any other insurance company to offer cashless claims to its customers. Furthermore, the industry is We will also collaborate to ensure that all hospitals are available as part of the cashless network to ensure that out-of-pocket expenses are significantly reduced and the amount of fraud is reduced.”

Health insurers told ET Wealth Online that this facility is going to be implemented soon. “The modalities are expected to be worked out by the beginning of the next calendar year,” says Ghosh.

“The initiative is in the final stages of implementation and should be implemented soon,” said another health insurer who spoke to ET Wealth Online.

Medical treatment will be more affordable
How will this help customers? Currently, if a customer goes to an unempanelled hospital for his treatment, he will have to pay first and get it reimbursed from his insurance later. In such cases, the responsibility of collecting the documents required for the insurance claim rests entirely on the customer. A significant portion of the claims filed for reimbursement go through multiple query cycles due to lack of vital documents which requires the customer to coordinate with the hospital multiple times.

Ghosh says cashless treatment in unempanelled hospitals can be a win-win situation for everyone. “For customers, this initiative will provide them with greater convenience as they do not have to worry about hospitalization as per their insurance policy, especially during a time when they are already free from the worry of hospitalization. are passing. Hospitals can also rest assured of settlement of bills as the turnaround time stipulated for t

he insurers to settle 100% cashless bills is 30 days,” he adds.

This move is likely to help in planned hospitalisations for several treatments. To know how it will be implemented for unplanned emergency hospitalisations, we have to wait for the final announcements by the insurance regulator.

“It is also a welcome move for the insurers as all genuine hospitals, that follow the right process and protocols will be empanelled as a part of this process, and the possibility of fraud, which is otherwise seen mostly during reimbursement claims, will come down. Overall, it is expected that health insurance will continue to be affordable for all,” Ghosh mentions.

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