Been at the hospital for a couple of days and now that you are fit, you crave home food and comfort. The doctor comes on a round and declares you fit for discharge and so you pack your bags thinking you will be able to walk out of the hospital the very next minute. But then the hospital staff tells you to have patience and that’s what you lose every single minute as you see your family running around to get the bills cleared. It’s now evening and you are still stuck because your health insurance claim has not been cleared and the hospital won’t discharge you unless the insurer signs off on the bills. This is not an aberration, but a common experience among the insured patients who make cashless claims.

"Insurance claims in India are generally delayed as there is no single point where claims can be verified. Also, hospitals and medical day-care centres are not listed on one platform due to which processing of insurance claims gets delayed. In an age where everything has become digital, electronic exchange of medical records between hospitals and insurance companies has to become seamless," said a spokesperson from GS1 India, an industry standards body.

The insurer in a cashless claim is usually the faceless entity as you are dealing primarily with the health insurance desk of the hospital and so you may think that the insurance company is taking their sweet time to settle bills, little realising that your hospital too could be guilty of delaying the whole process. It’s therefore important to understand the process.

Pre-authorization is the first step

The process of filing a claim starts with pre-authorization from the insurer. You and the doctor treating you will have to fill the pre-authorisation form. You will have to fill in the personal and insurance policy details and your doctor will fill in details about the treatment. Once this is done, the form is sent to the hospital’s billing department to give an estimate of the cost which is then sent to your insurance company along with the documents. The insurer reviews these documents and pre-authorizes the claim.

Pre-authorization usually means an initial amount has been sanctioned by the insurer along with an acknowledgement that the claim will be paid subject to final invoice received from the hospital. So it’s important to understand that a pre-authorization is a mere acknowledgement and not a guarantee that the claim will be settled. Even if your claim gets pre-authorized, you may be asked for additional documents later, approval of which could take time. If it’s an unplanned admission, you could be asked for a deposit by the hospital which gets reimbursed later. This is done because your admission may be sudden, not leaving you with enough time for the pre-authorization process.

The discharge day

Though pre-authorization has become quicker, claims settlement at the time of discharge could be a long and cumbersome process. In order to process the claim, an insurer will need the discharge summary which itself can take long. Once the discharge summary and hospital bills are sent to the insurer, it will scrutinize the bills before settling them.

Health insurance: Cashless claim ladder
Health insurance: Cashless claim ladder

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"Hospitals work primarily on the final bill settlement. So it’s important that your insurer or TPA give their final nod to the hospital for it to process the settlement. Sometimes hospitals submit irrelevant bills or documents to the insurer for authorization which leads to a delay," said Indraneel Chatterjee, principal officer, RenewBuy.com.

It’s important to know your claims settlement process will largely depend on the administrative efficiency of the hospital and the insurer. At your end you could check with the doctor for a probable date of discharge, also request for the time. Inform the insurance help desk and ask them to prepare the relevant documents so that they can be sent to the insurer immediately when the discharge is ordered. Keep calling the insurer or the third-party administrator to check the status.

Even in the best of hospitals, a wait time spanning 7-8 hours for claims approval and discharge is common, so a proactive approach will make sure you are able to get your policy to pay for your hospitalisation quicker and easily to a large extent.

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