Last year, in April, the regulator set a two-hour turnaround time for granting both cashless pre-authorization and final discharge of the insured patient.
Health insurance companies must now communicate their cashless approvals to hospitals within 60 minutes of receiving the authorization request along with any necessary hospital requirements so that there is no delay in discharge of patients and that hospital beds are not left unnecessarily occupied. The Delhi High Court ordered insurance companies and third party administrators (TPAs) to ensure that the time needed to grant a cashless approval was reduced as there were long queues of people waiting for beds due to the massive increase in the number of Covid-positive patients.
Fast turnaround time
The Indian Insurance Regulatory and Development Authority (Irdai), in a circular to health insurance companies on April 29, clarified that the decision to definitively release patients insured with Covid-19 will have to be communicated to the network provider within the next hour. from receipt of the final invoice with all other necessary documents from the hospital. Health insurance companies will have to order their TPAs to comply with deadlines specified by the regulator. Last year, in April, the regulator set a two-hour turnaround time for granting both cashless pre-authorization and final discharge of the insured patient.
The Delhi High Court has been informed that one of the factors delaying hospital admissions is that insurance companies are taking at least six to seven hours to authorize discharge of patients, creating a lag in the news. admission of Covid-19 patients.
Last week, the regulator ordered health insurance companies to file complaints against hospitals that do not provide cashless facilities and insist on cash payments from policyholders for treatment of Covid-19 while policyholders are entitled to cashless facilities as part of their policy. He advised insurers to ensure that policyholders are billed according to the rates agreed by network providers and also to ensure that hospitals do not charge additional fees for the same treatment other than the rates agreed with insurers. . The regulator also ordered insurers to ensure that claims for reimbursement under a health insurance policy are settled promptly in accordance with the terms and conditions of the respective policy contract and to issue appropriate guidelines in this regard to all. the TPA.
Settlement of complaints
In health insurance, a policyholder’s claim is settled either by a TPA or by the insurer’s internal claims processing service. A TPA is an intermediary appointed by an insurance company to facilitate the settlement of a claim. For claims, a policyholder should inform the APT who will search for all invoices and documents provided by a hospital to process the claim with the insurance company.
Upon discharge, an effective TPA will promptly process the complaint and negotiate with the hospital if there is a discrepancy related to the invoice. A policyholder must ensure that the TPA has adequate technological capabilities and a data security process in place. Insurers will only have the right to settle or repudiate a claim and the TPA can only convey the repudiation of a claim to the insured.
With the increase in the number of Covid-19 health insurance claims, most private insurers have opted for in-house claims settlement. In-house complaint handling speeds up turnaround times and the company team is more empathetic to customers. These teams can explain expenses not covered by the policy directly to them, and grievances can be resolved quickly.
However, the four public health insurance companies have their own TPAs for handling claims as they have no internal claims resolution process.
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