Popularizing Cashless Hospitalization

A
Agenda
d
Health Insurance – Evolution of Cashless

Current Market Dynamics

Future Market Movement

P
Practice
ti
z An Employer Employee Relationship

Reimbursement Mode – Employee gets

hospitalized, gets treated, pays and then submit
documents to the Employer for reimbursement

z Health Ins
Insurance
rance
z An Insured Insurer Relationship
Reimbursement Mode – Member gets
hospitalized, gets treated, pays and then submit
documents to the Insurer for reimbursement
M k tD
Market Demand
d
z Evolving Consumer demand:
z No Cash Transactions
z Hassle free E – Transactions

z Led to think:
z From Employer’s
z To manage employee benefits at optimum costs and move
away from operational management of claims
z From Insurers
z To offer cashless facility through
z Third Party (TPA’s)
Th 1st sprint
The i t
z TPA’s came into existence
z 2001
z Coordination between Insured + Insurer
z Introduced Cashless

z Concept of network hospitals

z Facilitated cashless transactions

Cashless Mode – Member gets hospitalized, gets

treated and walks off the hospital with no cash (cashless)
payment.

“ This arrangement
g led to increase in Health Insurance “
A
Agenda
d
Health Insurance – Increased penetration

Current Market Dynamics

Future Market Movement

St ti ti
Statistics
z Industry
y Utilization – Cashless:Re-imbursement
z 40:60
z Increase in costs for cashless transactions

z Reason for low penetration

z Spread of network hospitals across country
z Complex operational methods
z Low customer confidence of existing model
z Lack of standardization of definition of coverage
St ti ti
Statistics

z Reason for high cost of cashless

z Supply demand mismatch
z Lack of standard tariffs
z Lack of standard billing practises
z Lack of standard treatment protocols
z Lack os trust between providers and insurers
M k t progression
Market i
z Modes of cashless management
g
z Our first practice - continues
z Receive Fax for AL – Manual Process – Refax with approval
z E Platform
E-Platform
z Automated Process
z Hassle free settlement
z Biometric Smart Cards - RSBY
z 100% Cashless Policy
z Pre-defined packages
K Ch
Key Challenges
ll
z Operational
p Management
g – for increasing
g
penetration

z C tM
Cost Managementt – for
f sustainability
t i bilit
A
Agenda
d
Health Insurance – Increased penetration

Current Market Dynamics

Future Market Movement

F t
Future Market
M k tM Movementt
z Operational
p Management
g
z Lack of standardization across processes
z Complex & lengthy
z Education Series

z Cost Management
z Package based Tariff
z Preferred Provider Network

“Operational Excellence leading to enhanced penetration ”

O
Operational
ti l Management
M t
z Lack of standardization across processes
z Initiative at Industry Level
z Pre Defined processes
z Pre Set Tariffs
z Coding disease architecture

z C
Complex
l & llengthy
th
z E – Process
z Use of Bio Metric Smart Cards
z Type of RSBY initiative
O
Operational
ti l Management
M t
z Education Series
z Sales pitching point
z Mailers suggesting and highlighting benefits of Cashless
z Penetrate the user’s mind by
y spreading
p g WOM, Publicizing,g
through regular feedback and interaction mechanism
z Provider has to encourage the end user
C tM
Cost Managementt
z Standardization of Packages
z Packaged Based – Defined Cost for Surgical procedures
z For cases which cannot be packaged
z Stayy Charges
g –
z Professional Charges – Technical Teams Negotiates
based on historic data
z Investigation Charges – Technical Team keeps a check
and also based on discounts signed as per MOU
z Medicines/Implants/Consumables – Challenge area as
this is based on case to case negotiations
- Needs Standardization
C tM
Cost Managementt
z PPN – Preferred Provider Network
z Identify and tie up with N/W Partners
z Divert Traffic at onset
z Match Demand to Supply
z Mutual Benefit

“ Holistic Care ”
Thank You
C hl
Cashless Hospitalization
H it li ti
z How it works…
• Patient informs Insurance Co
Choose • Patient gets advise for choosing Hospital
Hospital

• P
Patient
ti t gets
t admitted
d itt d
• Pre Authorization send to Insurance Co
Admissio
n • Pre Authorization gets approved

• Customer ggets treated with care

Discharg • Walks out without spending any cash
e

• Network Partners sends claim to Insurance Co

N/W • Insurance Co settles the case
Reim
R i

z Cashless not only allows the customer to benefit from “no cash” but also gives
extensive care at efficient pricing
RSBY A
Architecture
hit t