Health is a basic human requirement and right and therefore its accessibility and affordability has to be ensured. The soaring medical treatment cost is beyond the reach of common man and in particular where a substantial chunk of population belongs to poor segment of society. To make matter worse Government control over expenditure for spend on social cause to keep physical deficit under control has added to the woes in the health care sector. Healthcare in India is in a state of enormous transitions though it remains highly under developed and less significant for masses. Health insurance is more complex than other segments of insurance business because of unavailability of data, Lack of information and moral hazards. Health sector policy formulation, assessment and implementation are an extremely complex phenomenon due to changing epidemicological, institutional and technological scenario.
Various challenges Indian healthcare sector faces can be summed up as under.
- Soaring cost in healthcare sector
- High financial burden on poor eroding their hard earned income
- Need for long term nursing care for senior citizens
- Increasing burden of new diseases and health risks
- Under funding of government healthcare preventive and primary care
Though General insurance business is growing at a comfortable pace , health insurance segment is racing ahead with a healthy compounded annual growth rate of around 28%.In spite of healthy growth rate health insurance industry is inundated with several teething problems which are hampering the expansion of the sector. The high claim ratio , increasing litigation with customers , dissatisfaction among insuring public for loading of premium as well as rejection of claims , delay by TPAs in processing cashless hospitalization and /or claims , delay by insurers in payment to TPAs , overcharging by hospitals to insureds are major problems hampering and jeopardizing the growth of health insurance industry in India.
Various steps are being taken by various stake holders involved to improve and do away with the problems being faced by health insurance sector. Regulatory authority and insurers are striving hard to streamline the processes involved so as to provide utmost services to the insureds and other stake holders.
Partially, the problems faced by health insurance sector can be addressed through induction of newer technology in particular for the process involving in claims management. It is highly crucial for insurance companies to ensure customer satisfaction for lasting relations with them. Seamless flow of operations in the claim settlement process is the key to win customer confidence. To address the problems faced by insurers, TPAs, various stakeholders and insured, highly versatile software has been developed by Anmol Technomart Pvt. Ltd. And has been launched under the brand name of “TECHNO SMART” which takes care of the following modules imperative for total automation right from the enrollment of the beneficiaries till generation of various MIS required by regulatory authority and various stake holders.
- Beneficiary Management Module
- Diseases/ Benefit Package Module
- Provider Management Module
- Enrollment Module
- Pre-Authorization Module
- Claims Management Module
- Utilization Management Module
- Provider quality Management Module
- Grievance Committee Module
- Audit/Fraud detection Module
Techno smart solutions enable various stake holders to speed up the entire process through exchange of relevant data at a click of few buttons.
For hospitals , it does away with requirement of manually filling in the forms , so any inaccuracy on the part of data operator in keeping the data error free and curtails any back end for error involve in document transfers. The data gathered from the patients at the time of pre authorization is directly fed on the TECHNO SMART platform which is accessible to TPAs and insurance companies immediately. It also eliminates the entire process of the insurance company/TPAs keying in data and scanning documents when they are received from the hospital. The amount authorized is also fed into the system and is available for all involved in the cycle thereby ensuring utmost transparency as IRDA is moving towards making various processes standards across the claim settlement process, shifting the data capturing, monitoring and exchanging to TECHNO SMART platform would make it convenient for the insurance companies and TPAs to adopt to the change.
Availability of structured electronically readable data enables automation of different aspects of the claims adjudication process resulting in greater accuracy in the approvals granted, reducing disallowances and revenue leakages resulting in to greater transparency and reduction of disputes.
“TECNOSMART SOLUTIONS” platform reduces the turnaround time from the stage of claims intimation to adjudication, authorization for cashless, processing of claim, settlement of claim, payment of claim and preparation of various MIS reports with greater transparency and authenticity with negligible instances of frauds resulting into better and favorable revenue spends.
“TECHNOSMART” product provides greater impetus for healthcare claim settlement infrastructure and scalable and can be customized as per the requirements. For the growth of the health insurance segment in India, it is imperative to embracing Techno Smart platform to provide much needed Philip to keep pace with the evolving global trends and best practices.
Prepared by
Mr. Bhavin H.Shah
Director – Anmol Technomart Pvt. Ltd.
