In the Reimbursement scenario, the onus is on the patient to duly submit all the necessary documents and share the information with the insurer as required for processing the claim.

Ref : OPD reimbursement section for the advantages and challenges in the reimbursement insurance.

Typical/existing workflow : For IPD service delivery and reimbursement insurance claim submission -

Workflow details :

  1. Individual/Beneficiary presents with a healthcare concern and reached out to the healthcare facility for treatment.

  2. Individual/Beneficiary is presented with a diagnosis and treatment plan.

  3. Individual/Beneficiary gets admitted to the healthcare facility for treatment. The patient is given the necessary treatment including tests, procedures and drugs). Post the completion of the treatment, the healthcare provider generates the bills and the same are shared with the beneficiary / patient

  4. The Individual/Beneficiary pays the healthcare provider the bill amount.

  5. The Individual/Beneficiary sends intimation to the payer(insurance company) about the treatment availed and requests for a claim to be initiated.

  6. Payer accepts the claim submission and shares a claim number with the beneficiary to track claim status.

  7. Payor reviews the claim information and documentation shared by the beneficiary.

(Optional) Additional info/docs required to process the claim

  1. If the payor needs, Payor reaches to the policyholder for additional information and documentation for adjudication.

  2. (Optional) If the beneficiary doesn't have all the information/answers/documents requested by the payer, they will have to reachout to the provider to get the necessary info or answers to queries or documents

  3. Provider provides the requested information and documentation to the beneficiary to file a reimbursement claim.

  4. Beneficiary responds to the payer with additional information and documentation to adjudicate the claim.

  5. Payer reviews the claim to decide necessary adjudication

(Optional) Field Visit

  1. The payor may contact or visit the patient to enquire and verify the claim submission

  2. the payer may also directly contact or visit the provider to enquire and verify the claim submission.

  3. Provider provides the necessary details to the payer. Updates based on the visit are shared with the provider to keep them in the loop. The payer will keep the beneficiary updated on the status of the claim.

  4. Observations from the field visit are shared with the patient

  5. The payer processes the claim and arrives at the settlement amount

  6. Payer informs the beneficiary on the settlement amount and details to support it.

  7. Final settlement amount is transferred to the beneficiary i.e policyholder.

  8. Claim is closed.

Reimagined workflow proposed by the work stream for streamlining claim submission:

Reimbursement work stream identified following optional enhancements to enable better workflow for the patients/payers:

  1. Comprehensive eligibility check or intimations: Comprehensive information about blacklisted hospitals, network hospitals, coverage limits and exclusions at the time of intimation

  2. Patient-originated pre-auth: Optional ability for the patient to seek a pre-authorisation for the Reimbursement claims prior to treatment. Pre-authorisation may be at a network or non-network hospital.

  3. Reimbursement to Cashless conversion: Optional ability to prompt the patient seeking treatment at a network hospital to convert to Cashless. Potential automatic conversion of “Patient-originated Pre-auth” to “Cashless Pre-auth”.

  4. Easy and secure delegation: Well-designed consent mechanism to allow the patient to assign a TSP, agent or another 3rd party to manage the documentation and communication on their behalf.

  5. Seamless patient-provider collaboration: More natural collaboration between the patient and provider in proving case documentation and query responses to the insurer by using forward mechanism from the protocol.

Below diagram depicts the reimagined workflow:

  1. Payor can communicate to the patient to opt for “cashless” for a network hospital

  2. Patient gets admitted to the healthcare facility for treatment.

(Optional) Pre-auth intimation to the payor after admission with the treatment plan and service charges.

  1. Policyholder/patient informs payer about the treatment plan with prescription documentation for pre-authorization.

  2. Payor responds to the policyholder with coverage limits and pre-auth details.

  3. Payer nudges the patient to convert to cashless if the hospital is a network hospital

  4. The patient is given the necessary treatment including tests, procedures and drugs.

  5. Patient settles all the outstanding bills and makes the payment

  6. Policyholder raises an insurance claim to the payor with all the treatment documentation and the provider bills.

  7. Payor accepts the claim and responds with a claim no. to track claim.

  8. Payor reviews the submitted claim information for adjudication.

(Optional) Payor needs additional info/docs to process the claim

  1. Payor shares additional info/docs required or queries to process the claim

  2. Policyholder request provider for additional information or documentation for claim submission.

  3. Provider responds to the policyholder with requested information about the treatment.

  4. Policyholder submits the provider shared information with the payor to support the claim.

  5. Payor reviews the submitted additional claim information for adjudication.

(Optional) Field visit

  1. Payer directly contacts/visits the patient to enquire and verify the claim submission.

  2. Payer may directly contact/visit the provider to enquire and verify the claim submission.

  3. Provider provides the necessary information to the payor

  4. Payor keeps the patient updated on the observations from the field visit

  5. Payor reviews the additional claim information shared by the provider for adjudication.

  6. Payor responds with claim adjudication information (Approved, denied, partially approved) to the policyholder.

  7. Payor transfers the claim settlement amount to the beneficiary/policyholder bank account.

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