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@Gautaamm : the thread. 1. Cashless mediclaim discharges : It's fairly common to experience delays in time taken for discharge of a cashless mediclaim patient. Let's understand the process and have a look at the common reasons. Also touching on some related issues. https://twitter.com/Gautaamm/status/1349400487557169152
2. Typically these hurdles are experienced more with emergency admissions as compared to elective cases. Requisite paperwork is usually complete during pre authorisation process before admission, which is followed for elective cases. May not be so for emergency admissions.
3. Emergency admissions, though authorised within 24 hours may run into trouble especially if intended stay and investigations pile up due to medical reasons. Be sure to submit all required documents within the stipulated time period (usually 24 hours).
4. A sanctioned Pre authorisation doesn't necessarily mean that entire bill amount will be approved at time of discharge by the insurer / TPA. More on that below.
5. Typically, as the in-charge doctor orders discharge, things are supposed to start rolling. The process is far from being free of hurdles, leading to delays. Most of this happens off the scenes for the waiting patient and family.
6. Delays may occur mainly due to 3 factors. 1. doctor / assistant/ hospital factors 2. Patient factors . 3.insurer/TPA related factors.
7. Once discharge is advised by doctor, the discharge summary is prepared, (usually by the assistant). The history, details of treatment / surgical procedure, details of implant if any, investigations, further advice etc need to be entered before it is sent to the insurer / TPA.
8. In case the concerned person is stuck elsewhere or certain details are not readily available, it consumes time. Hospital Softwares used nowadays have ensured that these details are available at a click, provided these have been entered earlier in the system.
9. One way of mitigating this is to identify patients due for discharge a day prior and leave necessary instructions to the concerned so that this end gets tied up well ahead of time. A discharge ordered or requested late in the evening may take time.
10. then hospital sends all these details to the insurer through mails/apps. expected turnaround time for them is 2 hrs. this can get easily extended due to any small discrepancy in documents submitted / lack of required documents / clarification demanded on certain points.
11. The insurer / TPA can raise queries to the hospital about their doubts. These could range from issues like agreed charges for certain Procedure, their exact breakup, consumables,, duration of stay in the hospital etc.
12. Typically the insurer will NOT pay separately for things like consumables, diet served in the hospital, co surgeon charges (cases where 2 surgeons have operated), assistant charges, nursing charges, cosmetic procedures. These get flagged and the queries need to be solved.
13. Certain day care procedures are usually not covered under cashless scheme. eg. Endoscopy / biopsies under local anesthesia etc. The patient is asked by the company to pay first and get reimbursed later. This has to be clarified prior to the procedure to avoid delays.
14. Typically, insured patient and family expect that they should not be made to pay a single dime for anything since they have been paying premiums. Because the fine print is never read or understood well. Typically,patient refuses to pay the charges that insurer has denied.
15. Patients need to be aware about their insurer, TPA (which may change often), amount they are covered for, and the fine print of exclusions. Many know only the agent who had sold them the policy, but are unaware of the details.
16. Improper history or conflicting history of illness will raise doubts about claim payability. So it's important that patient discloses truthfully all the facts. It's very common to see family hiding the exact duration of illness.
17. That one old MRI/CT report or an old forgotten claim which mentions contrasting history will cast doubts over the intent. Best is to not manipulate things and not bluff. That way one doesn't need to worry about the things stated in the past.
18. One needs to be aware of mandatory waiting period for certain Procedure (from policy inception) viz. TKR for OsteoArthritis - 4 years, cataract 1-2 years, etc. Expect a claim generated within one year of buying the policy, to be closely scrutinized.
19. Certain group (corporate) insurance policies may enjoy additional rider benifits (not available for individual policies) like pregnancy cover, dental care, coverage for pre existing illnesses and congenital anomalies. be aware about the same.
20. Various court rulings and insurance regulatory authority notifications mean that rules about pre existing disease cover / waiting period for different conditions / loading of premium keep on changing from time to time. Be updated on the rules.
21. Typically the room type the patient can avail is the one which costs (daily) around 1% of the total insurance cover. Enquire about the same, otherwise the difference needs to be borne by the patient.
22. Many aren't aware that the procedure charges are different for different category rooms despite the treating team and infrastructure being the same. It's not that only the stay charges differ. Consider it subsidy offered to general ward patient.
23. Only when the insurer/TPA is satisfied with the medical and billing details sent by the hospital, will they Authorize the payment after which the patient can go home. Any delay at any level will have cascading effect on the discharge time.
24. Sometimes, the representatives of the insurer/TPA do visit the patient in the hospital if they want to verify certain facts. The patient if not found in the hospital ( because of early discharge) leads to problems in claim settlement.
25. Also, there could be a co payment clause for a particular policy which makes it necessary for the patient to bear a certain percentage of the bill. Sometimes this is not known to the patient.
26. In short, there are a lot of things that may slow down the discharge process. In order to have a smooth ride, the patient, Hospital and the insurer / TPA all have to play their part well so that the experience is pleasant. (End).
