No more discharge delays! New system assures faster health insurance claims

"My father was supposed to be discharged at 9 am on March 10, 2024. We arranged a car to take him home and gathered friends and relatives. He was recovering from major heart surgery, which had gone well, but he was still fragile. The final discharge took seven hours because the hospital was trying to settle the insurance claim. This delay exhausted my father and left us anxious," recounted Shekinah, a 32-year-old woman from Kanpur.

However, this process is set to improve. HDFC Ergo General Insurance has recently processed its first health claim using the National Health Claims Exchange (NHCX) platform. This portal promises faster and simpler claim settlements.

 

What is National Health Claims Exchange (NHCX)?

The National Health Claims Exchange (NHCX) platform is a digital gateway created by the National Health Authority (NHA) and the Union Ministry of Health and Family Welfare as part of the Ayushman Bharat Digital Mission. It facilitates the exchange of claims-related information among insurers, third-party administrators, government schemes, hospitals, laboratories, and other relevant entities.

"We are confident that the NHCX platform will play a significant role by ensuring the interoperability of health claims, democratising insurance, and fostering transparency within the industry,” Ghosh said.

Benefits of NHCX

Currently, when patients visit a hospital, they provide their insurance details, and the hospital accesses various portals to upload the necessary documents for claim approval. This process is manual and time-consuming.

According to the National Health Authority, the current health insurance claims settlement process in India is manual, non-digital, and laborious, posing challenges such as:

- Difficult tracking of claims and reconciliations

- Insurers and TPAs receive uncoded data, which they must digitise, relying mostly on manual adjudication

- Patients face cumbersome claim processing with minimal communication and transparency

- Regulators receive delayed and incomplete data, with limited analytics due to lack of coding

How NHCX changes the process

With NHCX, most processes will be digitised and automated. A common claim format will be used across all insurers and hospitals, defined by the NHA. Hospitals can access digitised details of the insurer via the patient's Ayushman Bharat Health Account (ABHA) number. The NHCX portal will automatically validate the details before sending them to the specified insurer for digital verification and adjudication, leading to faster discharge processing.

Imagine Sarita, a patient who is undergoing treatment at a hospital. Currently, she provides her insurance details, and the hospital processes her claim manually, which takes time and lacks transparency. With NHCX, her insurance details can be accessed through her ABHA number, and the claim will be processed digitally and automatically. This means:

1. Sarita's claim will be settled faster, with cashless claims being processed within three hours.

2. She will experience reduced wait times and quicker preauthorisation and discharge approvals.

3. Sarita and other patients will benefit from reduced insurance premiums and broader claims coverage in the future.

Overall, NHCX aims to streamline the health insurance claims process, making it more transparent and efficient for everyone involved.

Faster claim settlement

Recently, the Irdai mandated that all cashless claims be processed within three hours of receiving a discharge authorisation request from the hospital. If there is any delay, the additional amount charged by the hospital will be borne by the insurer from the shareholder’s fund. Additionally, insurers must decide on cashless authorisation requests within one hour of receipt.

NHCX aims to:

1. Standardise and ensure the interoperability of health claims

2. Enable seamless data exchange between insurers and providers

3. Use FHIR-compliant e-claims format through a single gateway using standard protocols (APIs)

4. Enhance transparency and efficiency in claims processing

5. Reduce operational costs related to claims processing

Key stakeholders

Payers: State health agency, insurance companies, TPAs

Providers: Hospitals, clinics, diagnostic chains, labs, pharmacies

Insured persons: PMJAY beneficiaries, health insurance policyholders

According to the govt, the proposed benefits of NHCX are:

— Reduced wait times

— Faster pre-authorisation and discharge approvals from insurance companies

— Lower insurance premiums

— Expanded types of claims coverage in the future, including OPD and pharmacy bills