Wednesday, April 14, 2010

Insurance Claims Process - The future?

What started off as a query from Arijit M - Insurance Professional -
Manager Claims (National Level) at Reliance General Ins Co. Ltd on
Linked-in with the topic 'How can we use the mobile technology in Claims
servicing, Health top, renewals, premium quote' actually made me think
of a possible ideal future of the claims processing process between the
service provider & the back office of TPA/insurance.

Except for premium alerts, notices, and status update of the claim
stage, mobile technology is of not much use as a large amount of work is
done with interaction with personnel from provider and payer.

So how can technology & IT help in faster claims processing, the biggest
grouse of every stake holder including the provider, payer, and the
claimant (patient)?

I feel a web based service instead can be used for live claim
processing, input of data and attachment of scanned medical records by
the service provider for faster processing. Digital signatures can be
used to authenticate the files.

A network among all TPA/insurance back offices can prevent duplication
of claims for which original documents are sought from patients (which I
feel is waste of paper and time) on lines of CIBIL rating for loan

There were thoughts whether an integrated system which captures real
time data information like condition of the patient, proposed/final line
of treatment, day to day billing will bring about faster turn around
times in claim processing?

But then how will this real time capture of EMR bring in value and
expedite the claims process?

The medical treatment is not always as per the proposed line of care.

In India still the consultants have a 'problem' of data entry when it
comes to using computers (it's still better than the US where clinical
EMR penetration is very low).

Capturing of EMR (Forget real time) cannot happen until the application
and data entry is standardised across all insurance network hospitals.

Standardisation even if willing (by hospitals) will be a problem because
various software's would have various programming intricacies built in
to their existing software's which would make the modification &
integration difficult and leading to unnecessary cost overloads.

So what is the possible ideal future for the claims processing?
I could only think of this: I would propose an online simple web based
claim process form where all necessary claim related fields are filled,
and scanned copies of medical records are attached by the service
provider. But this should not follow a sending of hard copy as that
would mean duplication.

A CIBIL (Credit Information Bureau (India) Limited) like network would
prevent duplicate submissions where all claim processing back offices of
TPA/Insurance can log in & check the insurance history of patients akin
to the loan/credit history of the borrower. Patients can log in and see
how they fare & make appropriate amendments.


Dr Akash S Rajpal,
AGM Operations,
Dr L H Hiranandani Hospital, Powai.
NABH Accredited Hospital.
ISO 9001:2000 Certified (DAR & NABCB accredited)
"IMC Ramkrishna Bajaj National Quality Award" Winning Hospital.

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