Category: Blog

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.

17 Aug 2018
hic

Health Insurance Claims: The Basics

Gone are the days when health insurance was considered just another fancy term for an added expense you don’t really need. Today, there is a lot of awareness on how medical insurance can be your safety net in case of a medical emergency, be it an illness or an accident. There is also, the obvious benefit of tax savings!

Experts suggest that health insurance has become an essential element of any family’s investment plans, to combat rising health risks as well as skyrocketing charges for healthcare services.

Generally, an insurance claim can be done in two ways – cashless and reimbursement. Here are some pointers on how to go about making your claim:

Cashless Claims

A cashless claim can be made when you are hospitalised at a ‘Network Hospital’, or a hospital that is recognised by your health insurance provider. This is, undoubtedly, the best way to go about your claim because it saves you the burden of dipping into your savings and shelling out your hard-earned money for the treatment.

In terms of a cashless claim, most of the paperwork is taken care of by the hospital or the third-party administrator (TPA) your insurance company is linked with. A good policy provider would ensure that this process is fast and smooth, using a claims management application to do so.

If you are looking to make a cashless claim, you will need to:

  • Submit your policy/membership number to the hospital for preauthorisation from the TPA
  • Submit relevant documents relating to your personal information and planned treatment, which will be available at the hospital’s insurance helpdesk
  • At the time of your discharge from the hospital, verify and sign all the bills incurred
  • Leave the original bills at the hospital and keep photocopies with you for your reference

 

Reimbursement Claim

Reimbursement claims can be made when there has been a medical emergency when you have been unable to seek treatment from a network hospital. As the name suggests, this type of a claim is one wherein you are expected to pay all your bills at the hospital and later have them forwarded to the TPA for reimbursement. When you choose this method to make your reimbursement claim, it is important to make sure that all relevant documents required by your insurance provider have been compiled before the request is filed. This can save you the hassle of claim rejection and multiple resubmissions.

To process your reimbursement claim, you will need to:

  • Pay for all expenses incurred during and after the treatment at the non-network hospital
  • Collect all bills, documents and medical reports at the time of your discharge
  • Lodge a claim request with the TPA by submitting the relevant documents

 

Terms & Conditions

There are a number of variations in the health insurance plans offered by different policy providers. It is therefore key to understand, first and most important, the meaning behind that little asterisk (*) – the ‘terms and conditions’ of your policy.

Although it may seem like a long and arduous task, you need to take the time to read and understand what is and isn’t covered in the healthcare policy you are signing up for. Can you claim the expenses for outpatient treatment or is it restricted to hospitalisation? What is the total amount you can claim in a year? Are additional expenses like room rent and charges incurred for the care-giver covered? Are there limitations in the amount of cover received for specific treatments or certain health conditions? These are the questions for which you need to be finding the answers to as you read the policy document and make your decision to invest in the policy.

Knowing the answers to these questions ahead of time and understanding the specifics of your policy plan will help you be prepared when a need arises, and help you go about your claims procedure in a hassle-free manner.

10 Aug 2018
tpa

What is a Clearing House? Everything you need to know!

Clearing Houses, or Third Party Administrators (TPAs), coordinate between patient, insurer and hospital to manage healthcare payments from end to end.

The Clearing House or TPA picks up claims from your hospital’s billing software, gathers and processes documentation for each patient, and passes them on to the insurance provider. They coordinate with dozens of insurance service providers, for each patient who passes through your hospital.

Collecting documentation for each patient’s claim, filing electronic and paper claims in different styles and formats, receiving, analysing and recording reports from each insurer… it’s quite complicated for hospitals to make and maintain contact with so many different service providers!

Clearing Houses simplify this process significantly, allowing healthcare providers to coordinate with a single agency rather than with multiple insurance service providers.

There are invariably multiple claims every day against medical insurance, at a much higher frequency of claim than with life insurance, for example. As a result, it is in the interest of the insurance company to appoint a Clearing House or TPA as well. TPAs, just like insurance providers, are required to register with the Insurance Regulatory and Development Authority (IRDA) in India.

Each Clearing House is associated with a large network of hospitals and is responsible to manage all aspects of claims for these healthcare providers.

This includes coordinating with you with respect to patient care and treatment, passing on bills to the insurance provider, who pays the bills.

There are two ways patients can make a health insurance claim: Cashless Treatment and Reimbursement Treatment. A huge amount of paperwork (digital and physical alike) is generated on each of these types of claims, processed every day by the Clearing Houses.

If patients are making Cashless claims, the Clearing House collects documents from your healthcare facility and passes them on to the insurance agency. The Clearing House then coordinates with the agency and gets you your payment (usually via direct deposit) from the insurance provider.

In the case of Reimbursement claims, the patient makes full payment to the hospital. The Clearing House then assists the patient in coordinating claim process, approval and payment from the insurer.

The Clearing House simplifies the process, interfacing between hospitals and insurers to provide patients with the best possible experience.

Hospital staff have way too much on their plate to spend time helping patients process insurance claims, nor do healthcare providers typically have the infrastructure to allow multiple insurers to set up shop within the hospital premises. Equally, the last thing that patients want when they enter your premises is to work on figuring out what documentation they require to file a claim.

Hospitals, patients and insurance agencies… they’re all delighted to work with Clearing Houses to streamline the insurance claim process, saving time, money and heartburn all around!

01 Aug 2018
insurance1

A Definitive Guide to Health Insurance Claims

While entering a hospital for care, the last thing you want to have to worry about is how to pay for the treatment… especially when you’re already covered by health insurance! Unfortunately, if you’re not prepared, the avalanche of claims-related paperwork and processes can drain your energy and strain your patience.

As the experts in hospital insurance claims management, we at Attune would love to share some insights.

Step 1: Read Your Policy… As Soon As You Receive It

This can seem a daunting task in itself, as many of these policies extend to dozens of pages in length! However, it’s essential that you read and understand your policy well in advance of any requirement you face to actually make an insurance claim.

This way, you know:

  1. What is covered. Are you insured for outpatient procedures? What about tests? Is domiciliary support covered? Pregnancy?
  2. Where to go. A tight network of hospitals will allow cashless claims against your insurance policy. Identify which those hospitals are and which is the closest, so that you are prepared in an emergency.
  3. Who is insured. Ideally, you should know this one already! However, it never hurts to confirm just who all are listed on the policy as dependents.

Step 2: Learn the Terminology

There’s a lot of jargon when it comes to the world of insurance claims. TPA (Third-Party Administrator). Network Hospital. Cashless Claims. Dependents. Pre-existing Conditions. And that’s not even considering the medical terms!

When you come across a term that doesn’t make sense, don’t just assume you know what it means. Google it – or drop us a message at our Facebook page and our team will get back to you.

Step 3: Get Organised

Consult with the TPA representative or the hospital insurance desk to create a comprehensive list of documents to be submitted, in hard copy or digital format. Go through the list. Do you have them all with you? Make a list of all the documents you need from home and try to make a single trip to collect them all.

A number of documents needed for the Claim Submission will be provided by the Hospital during the course of treatment – prescriptions, invoices, bills from pharmacy, requisitions, and more. Maintain a file to keep all these documents in one place.

Step 4: Have Patience

Don’t rush your insurance claim submission. When faced with the prospect of spending time on paperwork or with your hospitalised loved one, few will choose the former. And yet, it’s better to invest the extra hours ensuring that the claim is filed correctly, than to go through the shock and distress of a rejected claim.

Once you have submitted your claim, follow up regularly – but be patient. Losing your cool or damaging your own health will not help speed up the process!

When it comes to handling hospital insurance claims, remember: don’t panic. The claims process can seem long and painful, but if you follow these four simple steps, you can easily and efficiently get the claim processed. Keep calm and take care of yourself and your loved ones. Reach out to the hospital, your insurance agency or TPA for assistance when you need it. Remember… you don’t need to do it all by yourself!

21 Dec 2017
Spectra Filmless

The Exciting Case of the Vanishing Films

Welcome to the Filmless Era of Medical Imaging Solutions

The world of medical imaging was revolving around films for almost a century, when the 1980s opened the floodgates into the digital era. With medical imaging solutions such as PACS transforming the radiology landscape, the distance between radiologists, patients, and care providers have drastically reduced. But one of the most radical changes has been the case of the vanishing films. Yes, cumbersome films and film viewers, which used to be commonplace in clinics and hospitals until recently, are suddenly disappearing! But no one’s really complaining about this change because medical imaging is now filmless, thanks to the digital era.

Is going filmless such an advantage? What benefits can this move bring to the radiologist, care provider, and the patient? Let’s take a look!

The Practical Problem with Films

For the patient
The entire medical imaging process can be exhausting for a patient when films are involved. The need to go back and forth between the care provider’s office and the imaging center to collect the films is often tiresome. In addition, it is the patient’s responsibility to store the report and the films carefully, carrying them during every visit to the care provider. The scope of misplacing the reports or swapping the films exponentially increases the possibility of error. These undesirable delays and error-prone practices often widen the gap between such diagnostic procedures and the final diagnosis of the underlying condition.

For the care provider
A care provider definitely needs to be physically holding the film to assess the report and make a diagnosis. The need for additional devices such as film viewers necessitates more appointments with the same patient before taking a decision. This would mean seeing lesser patients and increased stress. With no option to study the report in-depth, films limit the scope for an accurate diagnosis.

For the radiologist
The workload on the radiologist is definitely much higher, given the time and effort it takes to develop films and interpret the readings to create the report. The operational costs are also high, because of the additional resources required for managing patients who have to visit twice – once for the test and second for the report. Maintaining an accurate repository of the records is also a challenge. Hence, the entire radiology workflow is complicated because it revolves around efficient film management.

Filmless Imaging – the perfect solution

The perfect imaging solution that will resolve the pain points associated with films should focus on five critical areas: time, quality, error-free process, ease of access, and an intuitive user experience. Filmless imaging easily ticks all these boxes.

Filmless imaging for care providers
The ability to share images instantly is one of the biggest advantages of filmless imaging, giving easy access to images and reports. The zero-footprint DICOM viewer ensures a paperless experience and enables care providers to access images anywhere from anytime. Mobile-viewing capabilities in terms of pinch, spread, and swipe options deliver a consistent user experience to the care providers across devices. Care providers no longer wait for a second appointment with the patient to confirm diagnosis. They have real-time access to images and reports, which help them take a data-driven, timely decision about the diagnosis even before meeting the patient.

Filmless imaging delivers incredible support tools for performing in-depth assessments. Precision analysis tools and click-of-a-button options such as magnification, contrast, compare, matrix, cine, and flip support care providers in performing a detailed assessment and even comparing against earlier studies. The nano-compressed files help store high-resolution images without loss of space. Hence these images give care providers the power to zoom in to perform intricate analysis. Collaborative assessment with peers is also possible through easy image transfer options. These features ensure that care providers conduct a thorough and quick review before confirming the diagnosis.

Filmless imaging for patients
Patients no longer have to wait in queue to collect reports. They have easy, permission-based access to reports and images through desktops or mobile phones. They no longer have to carry around heavy films for their visits. Their repository of reports gives them the convenience to accurately share their medical information anytime from anywhere. This speeds up the treatment and ensures a positive patient experience.

Filmless imaging for radiologists
A comprehensive dashboard and workbench provides innumerable options for radiologists to do a thorough and quick job. Detailed windowing tools, options to annotate, and manage study lists helps them organize their work efficiently. In addition, extensive reporting templates with standard reporting terminologies decreases scope for error while creating reports. Advanced imaging options with client viewer integrations enable the delivery of a thorough and detailed report every time. The online repository of reports and images provide a quick reference library to conduct pattern-based studies.

Allaying Two Serious Concerns of Filmless Imaging: Security and Storage

Two of the most serious concerns about filmless imaging are security and storage. The robust, permission-based platform delivered by intelligent image management software ensures a secure and reliable option to store and manage reports and images. In addition, cloud-based solutions deliver the biggest advantage of a single version of data being accessible to every authorized stakeholder, reducing the chances for version issues.

Storage-related complications can easily be overcome through smart storage options delivered by DICOM-compliant imaging solutions. A well-organized online repository reduces clutter and supports an efficient query- and rule-based retrieval system. These approaches eliminate the hassles of server space and safety.

Conclusion: The Filmless Revolution in Medical Imaging is Here to Stay

The transformation into the filmless era is almost complete. The spectacular additional benefits brought by filmless imaging go even beyond convenience, time, and accuracy. This approach streamlines the entire imaging process and integrates with every aspect of RIS and HIS. This systematization of the entire imaging process is one of the biggest victories of filmless imaging. With potentially disruptive technologies such as AI and machine learning delivering intelligent solutions in predictive diagnostics, the symbiotic association of filmless imaging with such innovative solutions will definitely explore new horizons.

But the question you need to answer right now is, have you taken the first step toward film-less imaging yet? Click here for a free demo.

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