Mar 21 2024, 07:38
Inflated bills, ghost hospitals: What IRDAI has on its plate as it attends to health insurance woes:
Health insurance major Star Health put around 100 hospitals in excluded providers' list in Ahmedabad after it found their involvement in fraudulent practices. This irked Ahmedabad's prominent hospital association that threatened to discontinue the cashless claim facility. The clash between insurance companies and hospitals is back. Here's what IRDAI is doing to solve such relapsing tiffs.
On advice of his family doctor, Shyam, a resident of Ahmedabad, got admitted in a city-based hospital with a hope to get well soon. The first thing he was asked by the hospital staff was whether he had a valid insurance policy. The moment he said 'yes', the hospital warden smiled.
And then, his ordeal started.
In contrast to his family doctor's observation that he was suffering from a seasonal flu, the hospital staff started administering him a host of medicines which was followed by a series of costly tests, procedures, and many more.
It took him quite some time to know what was exactly going on. He had fallen victim to the fraudulent practice of hospitals making inflated medical bills to the insurer.
Similar cases have been happening across the country.
With the rise in public awareness, growing burden of non-communicable diseases in India, government policies and product innovations by insurance companies, the health insurance segment is expected to see robust growth in the coming years.
However, the tussles between hospitals and insurance companies relating to fraudulent claims and other issues continue to be a nuisance. The Insurance Regulatory and Development Authority of India (Irdai) has been working on this and taking several measures to tackle such issues.
The recent tiff:
In a letter dated September 5, 2023, Ahmedabad Hospitals and Nursing Homes Association, which represents around 1,000 mid- and small-sized hospitals in the city, wrote to Star Health about the problems faced by its member hospitals relating to cashless treatment and reimbursement of claims and delisting of hospitals by the insurance company.
The association threatened to discontinue the cashless treatment facility with the company if the issues are not resolved.
Star Health has put around 100 hospitals in excluded providers' list in Ahmedabad alone after it found their involvement in fraudulent practices which simply means that the insurer will not provide any cashless claim settlement facility to them.
In the entire country, the insurer has put around 1,000 hospitals in its excluded providers' list over the past 12-15 months.
Viren Shah, secretary of the association, told ET that Star Health has delisted about 100 hospitals in Ahmedabad without giving proper reason and prior notice or a chance for hospitals to respond. Hospitals are also facing issues of claims being denied after initial authorisation as well as delays in approval and settlement of claims.
Meanwhile, the insurer says it has allegedly found that many of these hospitals have been violating tariff rules and some engaging in frauds, and hence sent notice to them to discontinue cashless claims settlement, which allows direct billing to the insurance company by the hospital.
Both parties held a meeting a few days back to address this issue.
"We had a meeting with the hospitals' association in Ahmedabad recently as we keep monitoring very closely to some of the hospitals in Ahmedabad. The hospitals there have urged us to reconsider our decision to exclude them unless we find their involvement in any blatant violation of norms again," Anand Roy, MD and CEO, Star Health and Allied Insurance told ET.
A representative of Star Health, who had been sent by the company as its emissary to negotiate with the Ahmedabad-based hospitals and nursing homes, said that different stakeholders are having their varying thought process on the issue. "I have asked them to
present their concerns case-by-case. Once I listen to them completely, then only will I be able to study the entire episode and assess the situation. He hoped that the entire process would get completed even before October 14, which is a deadline set by the warring hospitals in
Ahmedabad to the insurer."
The insurer claims that it does not reject claims because the hospital charges are high.
However, there may be a few claims that require in-depth investigations due to an alert on
suspected fraud, either by hospitals, claimants, intermediaries or third-party aggregators.
Committee on common empanelment process of hospitals and 100% cashless Members' list
Head of the committee: Dr S Prakash
Former MD, Star Health
Krishnan Ramachandran MD & CEO, Niva Bupa
Inderjeet Singh
Secretary General, Gl Council
Pankaj Tiwari
GM-Health, IRDAI nominee
Sushma Anupam
GM-Health, New India Assurance
Usha Girish
GM-Health, United India Insurance
Atul Gujrathi
Joint President, HDFC Ergo General
Rajagopal Rudraraju
EVP-Head Health Claims, Tata AIG
Amitabh Jain
COO-Star Health
Dr Bhabatosh Mishra
Director-Niva Bupa Health
Dr Abhijit Ghosh
Shailesh Dubey
Head-Health Claims and Provider Management, Aditya Birla Health
Head-Health Claims, ICICI Lombard
source: et
Mar 21 2024, 09:07
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