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Author: Attune Technologies

16 Oct 2018
552396

What is Claims Processing? Definition & How it Works

Businessdictionary.com defines claims processing as “the fulfillment by an insurer of its obligation to receive, investigate and act on a claim filed by an insured. It involves multiple administrative and customer service layers that includes review, investigation, adjustment (if necessary), remittance or denial of the claim.”

Claims processing begins when a healthcare provider has submitted a claim request to the insurance company. Sometimes, claim requests are directly submitted by medical billers in the healthcare facility and sometimes, it is done through a clearing house.

In essence, claims processing refers to the insurance company’s procedure to check the claim requests for adequate information, validation, justification and authenticity. At the end of this process, the insurance company may reimburse the money to the healthcare provider in whole or in part. The company may also reject the claim request, if found invalid, forged, duplicated or outside of the policy terms.

Steps Involved in Claims Processing:

Primarily, claims processing involves three important steps:

  1. Claims Adjudication
  2. Explanation of Benefits (EOBs)
  3. Claims Settlement

Claims Adjudication

In this step, the insurance companies checks the following:

  • Has pre-authorisation been approved?
  • Does the claim match the details given in the pre-authorisation request?
  • Is the patient eligible for a claim?
  • Has there been any duplication in the claim?
  • Is the hospital in the approved network list?
  • Is the diagnosis valid?
  • Was the treatment medically necessary?
  • Has the treatment been coded correctly?
  • Is the claim request amount validated?

 

Insurance companies use a combination of automated and manual verification for the adjudication of claims. When this is done, payment determination is done, wherein the insurance company decides how much it is willing to pay for the claim.

Explanation of Benefits

When the adjudication process is complete, the insurance company sends a notification to the hospital, along with details of their findings and justification for settling (fully or partially) or rejecting the claim. This is known as an explanation of benefits or remittance advice. Based on the EOB, the healthcare provider may provide more information or request to represent the claim.

Usually, the explanation of benefits includes details such as: Amount paid, amount approved, allowed amount, patient responsibility amount (in cases of copay or coinsurance), covered amount, discount amount and so on.

Claims Settlement

This is the final step, where the insurance company settles the amount that it is due to pay the healthcare provider for the treatment rendered to the insured patient. This may be done, either individually for each claim made, or in bulk for all claims received from the same healthcare provider over a period of time.

09 Oct 2018
inscalims

Most Common Types of Insurance Claims

Insurance is a broad field with a variety of options. You can insure almost all areas of your life, be it your health, your house, your vehicle, or your business. You can even insure your life itself!

With more and more awareness on the usefulness of a good insurance as being a backup plan in case of unwarranted emergencies and as an ideal investment to go tax-free, insurance companies are also coming up with several policy types within each insurance category to help customers invest for more specific needs.

When it comes to most insurance policies, you are investing in something that you wish you would not have to claim. You wish you wouldn’t fall sick, but if you do, you are backed up by your health insurance. You wish your vehicle wouldn’t be in an accident, but if it is, you are backed up by your vehicle insurance. In the same way, the insurance company is dealing with you in the hope that you wouldn’t make a claim and that they wouldn’t have to pay you. However, in the real world, unexpected occurrences are inevitable, and so are insurance claims.

The most common types of insurance claims fall under the following categories:

Vehicle Insurance Claims

Accidents – major and minor keep happening on a daily basis. Moreover, with the law making it mandatory for every vehicle owner to possess a valid vehicle insurance, the number of claims are also more commonly made for two-wheeler and four-wheeler insurances.

Home Insurance Claims

In case there has been a mishap such as fire in the house, or if damage has been caused by a natural disaster such as a flood/storm/earthquake, a home insurance claim is made. Moreover, a home insurance claim can also be made if there has been a theft; where the claim can be extended to cover silver articles, jewellery and other valued items under the condition that these were kept within a locked safe in the house.

Health Insurance Claims

The rising cost of quality healthcare, the inevitability of unhealthy lifestyles and the frequent emergence of new and unheard-of diseases and illnesses – all of these factors, combined, are causing more and more people to rely on health insurance as a way to deal with their ever-rising health concerns.In the recent years, many employers have also taken up the responsibility of investing in the health of their employees and their dependent family members. This, too, has been a cause for the rise in the number of health insurance claims.

Maternity Insurance

Sold separately or as a subset of health insurance, maternity insurance has slowly but surely become a necessary element of the family planning process in most families. This has become especially useful to cover pre and post-hospitalisation expenses, in addition to the delivery charges, and any health complications identified with the infant at birth.

Life Insurance Claims

Life insurance claims are made either when the insured individual dies or when the insurance period ends (and the insured person becomes eligible for an endowment pay). As life insurance offers tax savings, it is often used as a way to make savings for the future. In case of a death, the insurance claim is made by the beneficiary assigned to receive the sum as designated by the insured person.

Flood Insurance

Although still an emerging trend in India, there are flood insurance policies that are provided and covered by the National Flood Insurance Program in the USA. This is a fifty-year old policy which has been providing affordable insurance to property owners and also to renters and businesses. In disaster-prone regions of the world, people also rely heavily on natural disaster insurance policies such as these to cover damages caused to property due to hurricanes, earthquakes and so on.

26 Sep 2018
accounting-bill

Medical billing for dummies

Here are some frequently asked questions about medical billing and their answers that will serve as your first lesson on the field of medical billing.

What is medical billing?

Medical billing is the process of submitting and following up on health insurance claims with the insurance company. This process is undertaken by a medical billing specialist with the support of the insurance desk team of the hospital or healthcare provider.

It is the responsibility of the medical biller to ensure that the service provided to the patient (who is insured with the insurance company) receives reimbursement. As part of this process, the medical biller sends an invoice detailing the treatment and the health services provided to the health insurance company on behalf of the healthcare provider. Therefore, when done efficiently, medical billing can optimise revenue performance for the healthcare provider. Today, most medical billers make use of specialised software which help in automating and improving the speed and efficiency of the process.

How is medical billing different from medical coding?

Both medical coding and medical billing are processes that are largely responsible for the smooth progress of the healthcare provider’s revenue cycle. Medical coding, carried out by a medical coder, is the process of assigning specific codes to the different health services rendered to the patient.

Medical billing, carried out by a medical biller, utilises the diagnosis and procedure codes derived from the medical record documentation to assemble all data concerning the medical bill or claim accurately and efficiently. Therefore, medical billing is a process that is dependent on medical coding.

What are the steps involved involved in medical billing?

The basic steps involved in medical billing are:

  1. Charge Entry
    • The medical biller, in this step, enters the charges for services provided to the patient. The charge entry also includes the appropriate linking of medical codes to services and procedures rendered during the patient’s visit.
  2. Claims Transmission
    • Once the claim has been properly completed, it must be submitted to the insurance company for payment. This step is called claims transmission or claims submission and is done electronically in formats specifically required by the insurance companies. Sometimes, clearing houses are used to reformat the claims in the format that matches the need of the insurance company.
  3. Monitoring of Adjudication
    • Once a claim is submitted to the insurance company, it undergoes a process called claims adjudication wherein the insurance company evaluates the claim and decides whether or not the claim is eligible for reimbursement based on factors including validity and compliance.
    • At the end of the adjudication, the insurance company sends a report to the healthcare provider. It is the medical biller’s responsibility to review this report and ensure that all procedures listed on the claim are accounted for. If there are any discrepancies, the biller will enter into an appeal process with the insurance company.
  4. Payment Posting
    • This step marks the end of the billing cycle and involves posting and deposit functions. Payment or settlement is received from the insurance company at this point, and the payment records of every patient are recorded in the billing management software.
  5. Patient follow-up
    • Medical billers follow up with patients whose bills are delinquent, rejected or partially paid to make sure that the payment due for the healthcare service, which has not been settled by the health insurance company, is received. This may involve contacting the patient directly, sending follow-up bills, or, enlisting a collection agency.

In conclusion, it can be said that the medical biller is the bridge between the healthcare provider and the health insurance company. Additionally, the medical biller may also be involved in supporting the insurance desk, communicating with the physician for clarifications and many such tasks that are related to the claims process.

12 Sep 2018
howitworks

How does health insurance work?

Are you one of those people who is still wary about health insurance? Then it is probably because you are still unsure of how it works! We have put together a few basics to help you understand what exactly a health insurance is, what you need to do in order to avail a health insurance and how a hospital goes about processing an insurance claim when you choose to pay for a medical treatment with the help of the insurance.

This should help demystify health insurance for you and help you with your decision to opt for an insurance policy.

What is the purpose of a health insurance?

A health insurance is like a backup plan, an investment that you dip into, just in case you fall sick or meet with an unexpected accident. You invest in a health insurance, slowly and in small amounts, because it will be difficult to pay a large sum for an expensive treatment you did not anticipate.

How to avail a health insurance policy?

It all starts with you choosing a health insurance company, and then selecting a plan/policy from a range of them provided by the company. This decision has to be made by assessing a number of factors including reliability of the insurance company, type of policy (individual/family), its specific provisions (what kinds of treatments it supports), how much you are willing to invest, and how much cover you think you require.

Once you have selected your health insurance and have been enrolled in the same, you will begin to pay a fixed amount, called the premium, every month. The premium amount varies across insurance plans, and depends on the total sum insured, deductibles, copayment and coinsurance terms, where:

  • Total sum insured: The total amount you are eligible to receive from the insurance company for treatments throughout the year.
  • Deductibles: A fixed, pre-decided amount until which you are expected to pay for your own medical treatment. The insurance company begins to pay for your treatment, only after you have finished paying this amount for treatment.
  • Copayment: A fixed amount which will be your share to pay while availing treatment. The remaining amount is paid by the insurance company. The copayment amount is variable for different kinds of treatment.
  • Coinsurance: Coinsurance is, again, your share to pay for a treatment or healthcare service. Usually, this is a percentage of the total amount incurred for the treatment.

When you begin to pay a monthly premium, you become eligible for medical treatment. However, in some specific cases, such as when you have a pre-existing disease (a disease you knew about before you enrolled for the insurance plan), there may be a waiting period ranging from a few months to a few years.

What happens when you go in for treatment with a health insurance?

If you want to use your health insurance cover for a medical treatment, it is best to choose a hospital that is listed as part of your insurance company’s network. A list of network hospitals is usually included along with your policy documents.

When you register at the front desk of the hospital, you or your family member must inform that you plan to use your insurance cover. You will be directed to the insurance desk, where you will need to provide the details of your insurance company, policy and policyholder number.

The hospital insurance desk will use these details to contact the third-party administrator (TPA) which the insurance company has hired to manage their claims, or the insurance company directly (in case they have an in-house claims management team). At this point, a pre-authorisation request is sent to the TPA by the hospital. A pre-authorisation is a decision by your health insurer or plan that a healthcare service, treatment plan, prescription drug or durable medical equipment is medically necessary. It is a decision that depends on your policy, and also assesses what procedures are covered and for what amount.

Once the pre-authorisation request is approved, you are admitted in the hospital. If the treatment plan changes during the course of your hospitalisation, the TPA will be contacted once again by the hospital’s insurance desk for an enhancement.

During your discharge from the hospital at the end of your treatment, you will be required to submit all relevant medical documents at the insurance desk. The insurance desk, in turn, submits these documents to the TPA.

The TPA then approves the treatment amount, wholly or in part, depending on the policy terms and your eligibility. If the whole amount is approved, then you will be discharged immediately; if only a part of it has been approved, you will need to pay the remaining amount before being discharged. The TPA then sends a settlement letter and credits the amount to the hospital.

How does the insurance company pay?

When you start paying your monthly premium, you become a member of a larger group of people who are all doing the same.

Since a large number of people pay to the insurance company, the company is able to provide when you or another member has a need for medical care. Thus, everyone’s combined payments cover everyone’s cost for care.

Want to know more about health insurance and how to go about making a claim? Our article on Health Insurance Claims: The Basics may provide the answers.

25 Aug 2018
top10

Top 10 Insurance Companies in India

It is always best to make a well-informed choice when it comes to investing your money. The statement holds true, even more so, when it comes to investing money in your health. A health insurance policy choice is as critical as putting all your eggs in one basket – you are entrusting a company with both your money and your health.

There are a number of factors such as settlement ratio, solvency ratio, network hospitals, variety and flexibility of policies, among others, that determine the efficiency and reliability of health insurance companies. Based on these factors, we have come up with this list of top insurance companies in India for you to consider when opting for a health insurance (in no specific order).

Apollo Munich Health Insurance Company

One of the main reasons why Apollo Munich is among the top-rated health insurance companies in India is definitely the familiarity of the name in the healthcare sector. Asia’s largest integrated healthcare provider, Apollo Hospitals Group has partnered with Munich Health, a world-leader in insurance. It is also a preferred health insurance company because of its wide range of health insurance plans for individuals and families.

Apollo is also on top of the chart when it comes to customer satisfaction, with quick turnarounds like 90% cashless authorisations in under 2 hours and 90% claim settlement within 30 days. While most other insurance companies offer coverage for only up to 2 children, Apollo Munich provides coverage for up to 4 children under a single family policy.

Moreover, as health check-ups are covered on completion of a certain number of claim-free years (variable according to the plan), policyholders find value for the money invested in their insurance.

Health Insurance Portability, a feature introduced by IRDA in 2011 is also well accepted and implemented through a smooth and simple process by Apollo Munich Health.

Star Health and Allied Insurance Co Ltd

Star Health and Allied Insurance Co Ltd is an award-winning health insurance company born out of the unified initiative of several insurance veterans in India. Founded in the year 2006, it has ever since been ranked among the top insurance companies in the country.

Over the years, the company has also been the recipient of several awards – the World Health Organisation (WHO) Award of Excellence in 2017 being just one among many others.

With unique health insurance plans designed specifically for diabetic patients, cardiac patients and persons living with HIV, Star Health is a preferred health insurance company for persons who have pre-existing diseases and require tailor-made policies suited to their specific healthcare needs. Another unique feature of Star Health is that a personalised doctor visit is arranged for all policyholders who get hospitalised.

Star Health and Allied Insurance is also India’s first stand-alone insurance company. It does not depend on an external Third-Party Administrators (TPAs), but handles all claims settlements through an in-house team. This, in turn, ensures a smooth and hassle-free claims process.

Moreover, with more than 8000 preferred network hospitals, policyholders have more hospitals to choose from when opting for cashless treatment.

Max Bupa Health Insurance Company Ltd

Max Bupa Health Insurance Company Ltd is a joint venture between Max India Limited and UK-based healthcare services expert, Bupa. Like Star Health, Max Bupa also has an in-house insurance claims settlement team and works independent of TPAs.

Keeping the traditional Indian family in mind, Max Bupa also offers a  unique plan for joint families, wherein 19 members can be insured together. It also boasts of a short waiting period of one year for maternity expenses coverage.

With a claims settlement ratio (CSR) as high as 89%, Max Bupa gives its customers the highest level of surety when it comes to claims. As per the IRDA report, Max Bupa has also addressed and resolved all customer grievances in the year 2016-2017.

At Max Bupa, policyholders who opt for a two-year policy also enjoy a 12.5% discount on the second-year’s premium; this makes it a much-loved policy choice among those looking for cost-effective options.

Religare Health Insurance

Religare Health Insurance is highly recommended and promoted by experts in the healthcare sector including Fortis Hospitals, SRL Diagnostics and Religare Wellness, making it a trusted name in the industry.

With a “no-claim bonus” feature, Religare offers an annual increase of up to 150% in the policyholder’s sum insured. This ensures that policyholders will no longer feel that they have wasted their premium unnecessarily.

Unique add-on policy features of Religare include air-ambulance cover when policyholders need to go for treatments that are unavailable in their city, and global coverage which provides cashless treatment across the globe!

Religare also offers one of the lowest waiting periods for maternity with plans that require only a 9 to 24 months of waiting period.

Cigna TTK Health Insurance Company

When global insurance company Cigna, joined hands with Indian conglomerate TTK, the Cigna TTK Health Insurance Company was born in 2014. This itself is reason enough for its exponential growth and fame in the industry in this short span of four years.

What makes Cigna TTK a preference for most health insurance customers is the absence of the co-pay clause. This applies to all plans, without exceptions of age or medical conditions.

Moreover, under the Pro-Health Protect Plan of the company, policyholders are given an all-inclusive coverage including room expenses, surgeon’s fees, nurses fees, anaethesia, blood, oxygen, medicines, drugs, and other consumables as well. With a plan like this, customers have literally no expenses and, therefore, nothing to worry about!

Cigna TTK also offers its customers the ability to opt for a completely tailor-made plan, so that each policyholder can choose only what is needed in their specific case and leave out the aspects that do not apply.

National Insurance Company Ltd

National Insurance Company Ltd is the oldest insurance company in India, with over 112 years of experience in the field. This public health insurance company offers a wide range of insurance policies, which have taken shape over the years, according to the transforming needs of the people.

Being a fully government-owned company, policyholders find it to be a trustworthy choice when it comes to investing their money.

Moreover, policyholders have a wealth of choice when it comes to choosing from among the 6000+ hospitals that are in the company’s preferred network.

With a wide range of mediclaim policies, this health insurance is preferred by many employers to offer a health cover for their employees.

The New India Assurance Co. Ltd

The New India Assurance Co. Ltd is a multinational general insurance company with its presence spread across 28 countries. It is also one of the oldest and widely preferred insurance companies in India.

Similar to the National Insurance Company, it is also a government-owned insurance company, naturally winning the trust of the people.

The company shares a common in-house TPA along with four other public sector insurance companies in India, and assures policyholders of a hassle-free claim settlement experience with greater transparency.

As with the National Insurance Company, The New India Assurance Company is also well-known for a range of mediclaim policies. A highlight of this company’s mediclaim policies is that it charges differential rates for customers, depending on the location of their location.

Asha Kiran, a special medical insurance policy of the The New India Assurance Company, is a policy made available with special benefits exclusively to families with a girl child.

Universal Sompo General Insurance Co Ltd

India’s first public-private partnership insurance company, Universal Sompo is a joint venture between Indian Overseas Bank, Allahabad Bank, Karnataka Bank, Dabur Investment Corporation and Sompo Japan Nipponkoa Insurance (the largest insurance company in Japan).

With over 17 policies to choose from in the area of health alone, Universal Sompo ensures that their customers have plenty of options to choose from when it comes to the important decision of investing in their health.

With a high claim settlement ratio of 73.47% and a healthy incurred claim ratio of 70.91%, Universal Sompo is a reliable option for those seeking a good health insurance policy.

Moreover, as per the IRDA report, Universal Sompo also has an exceptional record of 100.00% in resolving grievances, making it a company that is accountable and loyal to its customers.

HDFC ERGO General Insurance Company

HDFC ERGO General Insurance Company, the fourth-largest insurance company in India offers a plethora of health insurance policies, suited for the varying needs of its customers.

These health insurance policies not only cover hospitalisation charges in times of illnesses or accidents, but also take care of pre and post hospitalisation expenses, expenses for domiciliary treatments, and also day-care procedures that require no hospitalisation.

More than 6000 hospitals are part of its network, and offer easy access of cashless claims. Another feature that makes HDFC ERGO a popular choice is that there is no need for the policyholder to co-pay.

Bajaj Allianz General Insurance

Bajaj Allianz has emerged from the partnership between Bajaj Finserv Limited and Allianz SE.

Health cash is a unique add-on feature of the company, through which the policyholder receives a daily allowance during hospitalised days to cover all auxiliary expenses during the period.

The company also boasts of claim settlements within one hour, and 24/7 call assistance for settlement of claims.

Health Claim by Direct Click (CDC) is a feature in the Bajaj Allianz Insurance Wallet App that enables policyholders to raise health claim requests of up to Rs. 20000/- without the interference of a hospital or TPA, directly through the touch of a finger. In thise digital era, this paperless, time-saving feature that is much welcomed by all its customers!

All these features bring Bajaj Allianz into the top ten insurance companies in India, and it is no wonder that more than 2.9 lakhs health Insurance claims were processed by the company in 2017-2018.

Summing it up

This is not an exhaustive list – there are many other prominent insurance companies in India, each one with its own unique set of pros and cons.

We recommend that you go beyond just the basics, take the time to understand different policies offered by different insurance companies and then make the choice that seems best suited for you and your family.

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