Health Insurance: How can NHCE simplify the claims process for insurers?

Sudhir Deva, a middle-aged IT professional, went through a major surgery a few months ago. Even as he was struggling with his recovery, he had another thing that kept worrying him – filing his insurance claim. Since he got the surgery done at a non-network hospital because his preferred doctor worked there, he had to file a reimbursement claim within 30 days of his discharge. He found himself entangled in paperwork and multiple phone calls, each step fraught with apprehension. In fact, the process even involved a couple of visits to the hospital to get some documentation.

Sudhir is not alone; many policyholders had to go through a great deal of inconvenience even in case of cashless claims due to multiple rounds of communication between their insurer and the hospital. All this, however, would soon be a thing of the past as the National Health Authority and the Insurance Regulatory and Development Authority of India (IRDAI) have collaborated to come up with a groundbreaking digital platform that is set to revolutionize the health insurance sector in the country. Not just this, the operations have already started with the first ever claim being processed through the NHCX portal.

Now, policyholders like Sudhir can digitally track their status and get better transparency and visibility into their claims. Yes, even if they get treated in a non-network hospital. This seamless, efficient, and stress-free process is what the National Health Claims Exchange (NHCX) aims to achieve. No need for excessive paperwork or repeated follow-ups.

What is NHCX?

To put it simply, NHCX is going to be a single-window interface between policyholders, hospitals and health insurance companies. This single-window interface is expected to replace the current system which traditionally relied on manual paperwork and required a lot of effort from policyholders and the hospital.

Under the new system, a common digital standard format will be used to file the claim irrespective of the insurance company. Furthermore, NHCX will facilitate the exchange of health claim information between all stakeholders in a completely digital way. The system will not only be interoperable but also machine-readable and verifiable.

The vision behind NHCX is simple, yet pathbreaking. It aims at standardization and interoperability of health claims through a seamless exchange of data, documents and images between the insurer and the healthcare provider. This is expected to lead to transparent and efficient claims processing, resulting in convenience for the policyholder and reduced operational costs related to claims processing for the insurer.

How NHCX will revolutionize the health claims ecosystem

First and foremost, the NHCX will benefit consumers tremendously. It is expected to drastically reduce the waiting time for claim approvals. In fact, the IRDAI has recently mandated that all cashless claims would need to be cleared within three hours. This would be possible due to automation and standardization of the claims process.

Furthermore, by facilitating a seamless and quick exchange of health information between all stakeholders, NHCX would also make it possible to have claims serviced in a cashless manner in non-network hospitals. This is yet another welcome move by the IRDAI to promote customer-centricity in insurance.

NHCX would also substantially reduce manual paper-work by facilitating digitization of claims and health records from ABHA IDs. This would lead to better communication between the insurer and the consumer, and result in reduced uncertainty and anxiety for the patient.

Efficiency, transparency and uniformity

For insurance companies and healthcare providers, NHCX would mean a consistent and uniform platform for the exchange of health information. Automation of claims processing through the exchange would reduce the need for manual adjudication, saving time and resources. This can reduce administrative burdens and lower costs for insurers and consumers alike.

With advanced data analytics capabilities, NHCX can help insurers better understand market trends, consumer behavior, and risk factors. The data-driven approach to claims would also result in the accuracy of claims processing through more accurate pricing models, better risk management, and improved customer service. Furthermore, the standardized data would make it easier to detect and prevent fraudulent claims.

This will also help insurers stay compliant with evolving regulations by providing up-to-date information and tools for managing compliance requirements. This is a step that would also encourage innovation in product offerings and service delivery. This will make way for the development of new insurance products and features that better meet the needs of consumers.

Sarbvir Singh, Joint Group CEO, PB Fintech