Scope, Typical workflows and mapping to the protocol

The Outpatient Department (OPD) is a distinct component of a healthcare facility, such as a hospital or clinic, dedicated to delivering medical services to patients who do not necessitate overnight hospitalization.

Within the OPD setup, healthcare professionals provide diagnosis, treatment, consultations, and a wide array of medical services to individuals with conditions that can be effectively managed without requiring an extended stay in the healthcare facility.

Please note that the scope of OPD use cases has been limited to following key categories in the current version:

  1. Drugs/Pharmacy - High frequency, a large part of the OOO expenses, always needed as part of any OPD/IPD intervention.

  2. Diagnostics - Almost always needed in pre and post part of any IPD or OPD intervention, results in high OOP

  3. Consultations - Entry point of an OPD journey, medium frequency, crucial to start health journey

  4. Wellness - Wellness interventions involving Consultation, Diagnostics and Drugs/Pharmacy as they will be very similar to #1, #2, and #3 above (except that the policy could be issued by payers/sponsors other than insurance companies).

Prioritisation of above categories was done based on the following prioritisation criterions:

  1. Coverage - Services that cover most patients (using Pareto Principle)

  2. Critical - Services for which OPD insurance is most needed (cost, frequency, etc.)

  3. Ease of implementation - Well defined services & procedures and needing least implementation effort by the participants

  4. Core service - Most offered in current OPD products (Mostly covered in 1 & 2)

  5. Availability of insurance providers - Companies who are providing an OPD insurance to their existing consumers

Following subsections details out the typical workflows in the cashless anf reimbursement OPD claims usecase.

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