Navigating health insurance regulations: What hospital management needs to know

New health insurance regulations are causing a major upheaval in the healthcare sector. The aforementioned modifications are intended to improve healthcare services’ affordability, accessibility, and effectiveness throughout India. To guarantee compliance and improve patient care, hospital administration needs to be aware of these requirements.

Universal cashless hospitalisation

The launch of the ‘Cashless Everywhere’ campaign is among the most noticeable developments. All hospitals, regardless of network status, are now able to provide cashless hospitalisation to policyholders under this new framework. Cashless care was previously restricted to insurance provider-affiliated network hospitals, which caused problems for consumers who sought care at non-approved facilities. In order to facilitate cashless transactions with all insurance providers, hospital management should make sure that their administrative and billing procedures are updated.

Notification and admissibility criteria

Patients need to provide their insurance company with at least 48 hours’ notice before being admitted for elective operations. Notification should happen in emergencies within 48 hours after hospital admission. To prevent treatment delays, hospital staff members need to be taught to help patients with this notification procedure. Claims must also adhere to the insurance company’s policies and the admissibility requirements specified in the policy conditions. To ensure seamless claim approvals, hospitals must become familiar with these requirements.

Charges at non-network hospitals

Billing at hospitals that are not part of the network will now be determined by the hospital using the rates that are set for currently approved insurance plans. For their pricing structures to comply with these regulations, hospital management should examine and maybe update them. Trust between insurance companies and patients can be developed by ensuring billing transparency.

Expanded health insurance coverage

Several modifications have been implemented by the Insurance Regulatory and Development Authority of India (IRDAI) to increase the coverage of health insurance. It is noteworthy that all age groups can now acquire coverage for health insurance plans because the entry age limit has been lifted. Because they can now buy complete mediclaim plans without age restrictions, senior persons will especially benefit from this. Senior patients seeking insurance-covered therapies could overwhelm hospital staff, so they should brace for this.

Reduced waiting periods

Pre-existing disease coverage now has a three-year maximum waiting period instead of a four-year maximum. In a similar vein, the waiting time for certain illnesses and treatments, like joint replacement surgery, has been shortened to three years. To speed treatment plans for patients afflicted by these illnesses and to better inform patients, hospitals should be informed of these changes.

Inclusive policies for severe medical conditions

Insurance companies are no longer allowed to deny coverage to customers who have serious pre-existing diseases, like AIDS, cancer, heart disease, or renal failure. The goal of this action is to establish a more diverse medical insurance market. Hospitals should be ready to handle the growing number of patients with complicated medical histories requesting insurance-covered therapies.

No sub-limits on AYUSH treatment

AYUSH (Ayurvedic, Yoga, Naturopathic, Siddha, Unani, and homoeopathic) treatments no longer have sub-limits. As long as they use the AYUSH therapy, policyholders can now collect the full amount covered. Hospitals that provide AYUSH services ought to make sure that patients are completely aware of their coverage alternatives and adjust their billing procedures accordingly.

Customised plans and dedicated support channels

It is now mandatory for insurers to provide tailored health insurance plans for specific populations, including pregnant women, elderly people, and students. To address elderly people’s grievances and claims, a specific support channel needs to be set up. Hospital administration should think about creating specialised divisions or educating current employees to meet the unique needs of these populations.

Moratorium period and indemnity policies

The eight-year health insurance ban has been shortened to five years. With the implementation of this modification, insurance companies are no longer allowed to deny claims because a policyholder concealed pre-existing medical issues after five years of continuous coverage. Furthermore, to guarantee that a certain amount is paid upon the diagnosis of a covered illness, insurers are now required to exclusively issue benefit-based policies for hospitalisation costs. To enable prompt and accurate claim processing, hospital billing departments must adapt to this new policy framework.

Prompt claim settlement

Insurance companies are required by the IRDAI to resolve cashless claims in three hours. The insurance will pay the additional sum that the hospital charges if there is a delay that lasts longer than this period. If an insured person passes away while receiving treatment, the insurance company is required to file the claim right away and release the deceased person’s remains. The administration and billing departments of hospitals should make sure they have the tools necessary to complete these tasks effectively. Within 60 minutes after receiving the request, the insurer will make a decision regarding the cashless authorisation. At the latest, on July 31, 2024, the insurer must put in place the required systems and processes.

In conclusion, hospital management has both opportunities and challenges as a result of the new health insurance legislation. Hospitals may raise operational effectiveness, guarantee regulatory compliance, and improve patient care by remaining aware and responding to these changes.