K Srinivasan
ON July 9, HDFC Ergo announced that it had successfully processed its first claim through the National Health Claims Exchange (NHCX) platform. In a release, the company said: “This marks a significant leap forward, which will help streamline health claims processing, improve administrative efficiencies, and enhance customer experience by building a cohesive technologydriven system.”
So what is the NHCX and why is it transformative for the healthcare business and, more importantly, for crores of patients who hold policies across dozens of companies? How does the National Health Claims Exchange platform work? To put it simply, the NHCX platform is a single-window digital platform developed by the National Health Authority (NHA) and the Ministry of Health and Family Welfare as part of the Ayushman Bharat Digital Mission.
Information gateway What it does is to act as a gateway for communicating claims information among various institutions involved in the process including insurers (like HDFC Ergo), third-party administrators (TPAs are responsible for processing health insurance claims admissible under the mediclaim policies of insurance companies which usually outsource their claim processing to third parties, who are the ones who approve the claims), Government scheme administrator and ‘providers’ (hospital, laboratories, polyclinics), beneficiaries and other stakeholders at one place. It will replace the current ossified system of excessive paperwork and a huge amount of sweat from policyholders and the hospital to work with the TPA and then wait for the TPA to greenlight their claims
Under the NHCX, a common digital standard format will be used to file the claim irrespective of the insurance company. What it means is that even if they get treated in a non-network hospital (hospitals that have not been approved by an insurance company), NHCX as the interface will drive the health claim data between all stakeholders across a digital highway that will not only be interoperable but also machine-readable and verifiable. For policyholders what it means is the ability to digitally track the status of the claims in a very transparent manner.
Boon for consumers What are the benefits? At its core, it will be a boon for the consumers or policyholders. Foremost, it will dramatically reduce the waiting time for claim approvals. This comes on top of the recently-mandated IRDAI ruling that all cashless claims would have to be cleared within 120 minutes of the receipt of a discharge authorisation request from the hospital. Only automation and standardisation of the claims process can help create such a swift process.
That apart IRDAI specified that for any delay over three hours, additional costs at the hospital, if any, shall be borne by the insurer from the shareholder’s funds. The icing on the cake is that the IRDAI specifies that the insurer has just 60 minutes to confirm the request for cashless authorisation.
The other great benefit of this phenomenal leap in mediclaim settlement is the multiple uses of the advanced data analytics capabilities that will help run this highway with the amount of data collected being humongous. It will have multiple benefits across the value chain. For example, the data will help companies like HDFC Ergo have a far better understanding of market trends, consumer behaviour, and risk factors.
Secondly, this data-driven approach will invariably result in helping detect and prevent mediclaim frauds, provide for more transparent processing that would help in more accurate pricing for superior risk management and improved customer service
Careful monitoring But all is not hunky-dory. For example, other elements need careful monitoring. The prime reason is the data available with many other institutions like stock market companies, mobile phone operators and real estate companies have not been preserved with the sanctity such data ought to have. That the mediclaim highway could also go the same way is a serious worry. Therefore, it would be important to ensure the privacy and security of sensitive medical history and claims-related information. The claim so far is that NHCX is committed to strict data protection regulations. But one will have to wait and see.
It is also critical to ensure that a large mass of staff that requires training to move onto the digital highway is efficiently trained to deliver services and protect data. This will be the key to the success of this programme.
