Cashless hospitalisation easy to preach, difficult to practise

Cashless hospitalisation easy to preach, difficult to practise

Birender Ahluwalia

Insurance Regulatory and Development Authority’s (Irda) recently announced draft norms on access to healthcare for the insured and cashless hospitalisation are the much-needed intervention for the insurance industry. How often do we hear about claims not being paid and cashless hospitalisation being a myth? Sadly, quite often would be my answer. The concept of cashless hospitalisation, though a novel one, has been non-trivial to implement. Finger pointing is unfortunately common. And stuck in between these arguments is the hapless policy holder, the patient. An eye-opener Walking through the policy holder’s plight might be an eye-opener for many. All health insurers, big or small, claim to provide the benefit of cashless hospitalisation. While selecting a policy, this is an important consideration for the buyer. It is quite difficult for the commoner to assess which of the options at hand would actually hold true when the moment of truth comes – are these really ‘cashless’ policies? Where are these ‘cashless’? How much amount is considered ‘cashless’? And then there is the persuasive sales representative, who over-promises. The buyer, unfortunately, opts for one of the options in the hope of promises being kept. The reality unfolds at the time of hospitalisation, where the patient walks into a hospital and is told that either the cashless facility is not applicable to that particular hospital, or the procedure not covered, or else, the limits approved are low. Oftentimes, the hapless policy holder is caught in the fight between the hospital and the insurance provider over past dues and prices of procedures. More often than not, the policy holder foots the bill in the hope that a re-imbursement would eventually happen. Well, not too bad, one may think, given that it is likely that the reimbursement would eventually happen. Far from the reality! Footing the bill when denied the cashless option is non-trivial. The costs of healthcare have seen a dramatic rise. Early and better diagnosis, better drugs and therapy and sophisticated equipment translate into better treatment, but highest costs too. For perspective, bills for major diseases shot up by 27% between 2007 and 2010. If you are still wondering, here is another fact: heart disease treatment could set the policy holder back by `2-5 lakh today. The right price The tussle on what the “right” price of a procedure is has been on for a while. Top super specialty hospitals employ the best healthcare talent, state-of-the-art equipment and processes which have an impact on the clinical outcome. It is justified that their costs for the same procedure would be different than another hospital which is not operating at the cutting edge. This leads to a disparity and non-standardisation in bills for the same procedure and forms the crux of the dispute between the payer and provider. The four public insurers, namely, National Insurance, New India Assurance, Oriental Insurance and United India Insurance recently de-listed 18 hospital chains claiming that they were ‘over-billing’ the insured. This marks a peak in the aforesaid “tussle”. Insurance companies wish to have predictability in claim expenses and therefore would like to negotiate and fix the cost of treatment for different procedures and conditions. This is a well-established practice in the West, where every procedure is coded and reimbursement amounts are stated clearly and transparently. The tussle on where an insured policy holder could get access to healthcare in general and cashless healthcare in particular, has prompted Irda to issue detailed norms. They key points which are proposed are as follows: 1. Pan-India access: All health insurance policies should allow access to healthcare, both in network hospitals and non-network hospitals with the exception of unauthorised hospitals 2. Transparency in the policy forms: Insurers would have to clearly state the terms of conditions of accessing treatment pan-India and spell out the terms which are different 3. Cashless hospitalisation: All insurers would have to transparently share the list of network hospitals and update the end-user in case there is any addition or deletion in the list. All hospitals listed in the “preferred network” or under “network providers” would collect payments directly from the insurers (subject to the approved limits), making these hospitals locations for a cashless treatment for the policy holder This transparency is bound to benefit the end-user who today is confused with the nuances of terms and is caught in the tussle between the payer and the provider. Implications for the consumer It is obvious that a ‘cashless’ feature is of major help when the policy holder is undergoing a procedure. There is no pressure to organise for the hefty treatment bill and running around for re-imbursement is avoided. So, what should a policy buyer look out for when making the decision to buy a health insurance policy or not? 1. What is the number of hospitals in the preferred or provider network of the insurers? 2. Are the top-end specialty and super-specialty hospitals included? 3. Are some convenient options in the town/city of his/her residence included in the list? Essentially, the larger the network hospital presence, the more the depth, the better the quality of those in the network, the better for the buyer! We at Max Bupa recognise this and strive constantly to add to the 1,200 provider network, bringing the top hospitals within the network. I am sure other reputable insurers are doing the same. This in the end is good for us insurers, the end user who has more ‘cashless’ options to choose from and also for the hospitals as they get more patients as consumers. The writer is director, sales and distribution, Max Bupa Health Insurance