Efficiency in healthcare administration – A tech driven approach to streamline cashless claims

India leads the world in terms of cost-efficient digital services across several domains – most notably in the financial sector. Indian stock markets are some of the fastest, with a T+1 settlement cycle. We have some of the fastest payments systems in the world too.

However, this scale of technology impact is largely yet to be seen in the ‘I’ of BFSI. Insurance processing still seems to be stuck at a level of technology Banks had gone past over ten years ago. In the world of health insurance, getting a claim settled still involves an inordinate amount of paperwork that bogs down patients, families and hospital staff alike. Insurance payments routinely take months to get settled.

So how does one go about solving this?

With modern technology of course. There are several promising avenues of process digitisation that can improve the experience of all actors involved in the health insurance claim process.

Digital documentation

First and foremost, we have to leave the paper behind. While there are several challenges, going fully digital for claims processing allows for the most drastic improvements. Thankfully, IRDA has permitted several private insurers to process claims on digital documentation, leading to a much smoother claims experience with them.

 Fraud detection

One of the major reasons insurance as a sector has stuck with paper based processing is the concern with the possibility of fraud if digital documents are allowed. However, the banking sector is proof that digital documentation does not increase fraud risk, if at all anything it decreases fraud risk by employing modern encryption and fraud detection technologies. Machine learning algorithms can be used to identify several kinds of fraud, which is not possible in a paper-based process.

Automated data entry

To file a health insurance claim, medical documents have to be produced, the same information has to be replicated in claim forms, and once again, the same information has to be entered on the TPA systems. Automating data entry using OCR/ICR technology can significantly reduce the amount of time taken to file a claim.

EHR/HIS integrations

Electronic health record systems, and Hospital information systems are for the most part not connected to insurance systems today. Having a middleware to manage health insurance claims on the hospital side with minimal human intervention would save a considerable amount of time spent in manually moving documents from one system to another.

Proactive communication

There is no dearth of means of communication in the world that we live in today – modern technology enables insurance firms and hospitals to inform patients about their claim process in real time. While this may not improve the pace of processing, it certainly improves the experience of the patient by keeping them informed.

Artificial intelligence

A lot has been spoken about how AI can transform claims experience – however, it is not the lowest hanging fruit on the tree – there are probably easier wins that hospitals and insurance companies can have with simpler tech. And yet, one cannot deny the potential utility of AI in insurance processing. Automated assessments have been an industry goal for some time now, and several insurtech startups have made considerable progress in this area.

Blockchain technology

Despite spotty acceptance in insurance circles, blockchain continues to hold strong potential for future applications, especially to prevent fraud and ensure secure, transparent, transactions.

Abhishek Sinha

Claims exchange

Having a national claims exchange is a great way to ensure standardisation of documentation and process while creating additional avenues of fraud reduction and control. While this is not in the hands of the Insurers and Hospitals, as a matter of policy not only has the Indian government endorsed it but has all intentions of making it mandatory. A claims exchange can facilitate features unavailable to users today.

For example, if a patient has two health insurance policies, they have to choose which policy they want to use for cashless treatment. In case sum insured is exhausted and the patient needs to claim from the other policy, this usually ends up having to be filed as a reimbursement claim causing short term financial distress to the patient. With a claim exchange the patient could potentially claim cashless across multiple policies subject to applicable rules.

Extensive use of technology to manage health claims is the only way to make the claim experiences simpler. However, this has to be done judiciously as any solution that is being built has to ensure data security and protect the privacy of patients. In a country with one and half billion people, using technology may be the only way to ensure good service delivery in insurance processing. Insurance companies & hospitals need to start embracing the use of technology in claim processing to enable the next leap in healthcare delivery.

Disclaimer: The views expressed in this article are those of the author and do not necessarily reflect the views of ET Edge Insights, its management, or its members

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