Context

Need for a new approach

Overview of the Current Process

The current claims filing and processing experience is fairly manual in nature.

Patients usually reach the hospital and provide the hospital with either the policy details or a card issued by the TPA. The hospital fills out the pre-auth/claim form by hand, scans all the required documents that need to be part of the claim, and sends these to the appropriate Insurance or TPA typically over email. Several TPAs/insurers also provide hospitals with their own electronic portal where their claims can be submitted as an alternative to email.

On receipt of the pre-auth/claim form, the Insurer/TPA verifies and digitizes the form in the software they use internally for claims processing. The team then adjudicates the claims. A large portion of adjudication in India is currently manual while many developed markets auto-adjudicate over 90% of their claims.

A response to the pre-auth/claim is sent back to the hospital over email. Payments are done electronically and notifications for payment advice are sent via email.

All insurers have to report claim details in a specified format to the Insurance Information Bureau of India (IIB). This is done on a monthly basis by each insurer.

(Reference: NHA IRDAI Joint Working Group Report)

Challenges of the Current Process

• The current claims exchange process is not standardized across the ecosystem

• Most data flow is PDF/manual

• High variability of process between insurer/TPA/provider

This results in:

• Multiple follow-ups, lack of visibility

• Long receivable cycles

• High cost of processing

• Poor scalability

• Poor patient experience

Inspired by the recommendations of the Joint Working Group of NHA and IRDAI (2019), these specifications have been developed over the last 12 months by 50+ volunteers from across the healthcare ecosystem (including Insurers, Hospitals, TPAs, Insurance Technology players and Think tanks), as a part of a transparent, collaborative and open effort anchored by Swasth.

The goal is to create an open, widely agreed Health Claims data Exchange Specifications as a public good that can be adopted. Specifications in this context refer to the blueprint of each aspect of the envisioned claims network and are fundamental to the working of the network. They have been carefully designed to be open to support technology and vendor neutrality, evolvable over a period of time thereby helping adapt to changing needs, enable and not restrict innovation or inclusion. These Health Claims Exchange Specifications for Cashless Insurance are now being published for public consultation and we seek your feedback for the same.

Questions for Consultation

Question 1

This consultation document takes forward the recommendations set up by Joint Working Group of NHA and IRDAI (2019), which talks about the challenges and limitations of claims processing and advocates the setup of the data exchange mechanism (called HCP in the paper). What are the incentives/disincentives for various stakeholders to participate? Please provide the list and mention the role and description of the stakeholder.

Question 2

As a stakeholder in the health finance ecosystem, what benefits or risks do you see of implementing such a data exchange process? How can the risks be mitigated?