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Health insurance claims

[This article was published in the June 2008 issue of the eHEALTH Magazine (]

Health insurance claims processing in ndia is not in the best of shape.

Health insurance claims processing in India is not in the best of shape. Patients and/or their relatives end up having to spend a lot of time, effort and resources on filing requests, following up payments and in many cases also having to deal with faulty billing. There is a strong need for healthcare reform and greater health insurance uptake. Revenue cycle leaders are struggling with tighter budgets, increasing scrutiny over billing and collection practices, new legislation, rapidly evolving technology, and payers’ changing rules. The industry also has to deal with the rising numbers of the uninsured and underinsured patients, shrinking reimbursements, and to add to this rising costs amplify these challenges. Issues that are most likely to impact the health insurance sector over the next five years include unpaid care (e.g., write-offs, bad debt), policy/regulatory issues, and delayed payment for services.

The Solution
A group of professionals belonging to HealthSprint Networks Pvt. Ltd., Bangalore have designed iSprint Health Insurance Electronic Claims Network, the first of its kind network in India for insurance claims processing. The aim of this network is to provide patient friendly health insurance transaction platform, which enables smooth transfer of health insurance related data with complete privacy and security. One of the most important service offerings of this team is focused on making Patient/Payer/Provider communications more clear, correct, concise, and patient friendly. The ultimate goal of the network is to ease the experience of patients and their families, but hospitals and medical groups also benefit in the process. Providers adopting the network experience considerable operational and financial improvements, due to the standardisation and inter-operability.

Product Development
HealthSprint Networks began its work by conducting surveys of focus groups of patients, payers and providers around the country. The participants’ message was loud and clear – patient billing is a significant problem for both patients and providers. Participants said they saw the patient bill as confusing and over-charging; they found the billing process time-consuming and frustrating. Consumers today expect to participate in their medical care and to be better informed about all aspects of their health. As the amount paid by consumers for medical care increases, patients more than ever demand and deserve financial information in a comprehensible format. Even though many organisations and entities are comfortable with the concept of paying bills online, healthcare lags behind many industries in adopting electronic billing options.

Important Components of HealthSprint Statement
Clear: All financial communications should be easy to understand. Providers and payers should be able to quickly determine what they need to do, with the communication enabling quick decision-making.

  • Correct: The bills or statements should not include estimates of liabilities, incomplete information, or errors.
  • Concise: The bills should contain just the right amount of detail necessary to communicate the message.
  • Patient Friendly: The needs of the patient and their family members should be paramount when designing administrative processes and communications.

The software and network components cover all important aspects of Cashless Claims processing namely, e-Preauth which eliminates the need to fax pre-authorisation forms and shrinks turnaround time dramatically; e-claims – which sends the information related to billing and necessary medical information to validate a claim, thus eliminating the communication issues after the discharge of the patient. It dramatically helps to improve the Payer Provider relationship which is the need of the hour and helps providers build effective Customer relationship management; e-Payment Gateway – after validation of the electronic and physical claim, iSprint enables seamless payment gateway secured through Unit Trust of India (UTI) Bank payment gateway to enable electronic fund transfers /RTGS to providers.

Benefits of the Network

  • Some of the immediate expected benefits of implementing the network are:
  • Improved satisfaction, operational efficiencies, and revenue cycle metrics
  • Patient satisfaction with the billing process
  • Days in accounts receivable
  • Cash collections improvement (cash collections such as revenue and bad debt expense)
  • Changes in bad debt and account aging
  • Change in billing/service calls per account
  • Readability of financial communications.

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