In the ever-evolving landscape of healthcare, the National Health Claims Exchange (NHCX), introduced by the National Health Authority (NHA), stands as a beacon of efficiency and innovation, reshaping the way hospitals, insurers and TPAs interact. Let us delve into how NHCX addresses the issues plaguing the healthcare cashless claims management process and promises to deliver the much needed efficiency.
Traditional Cashless Claims Management Process:
In the traditional claims management process, hospitals are grappled with fragmented information exchanges. Each insurer/TPA maintains distinct portals for claims management, and a few lack a portal altogether, relying solely on email as the communication channel. The process of managing claim approvals and reconciling payments varies across insurers and TPAs and is often cumbersome for hospitals. Such complexities lead to delays in capturing claim approvals or responding to queries from insurers and TPAs. These obstacles not only increase cost of claims processing and disrupt efficiency of working capital management for hospitals, but also adversely affect the patient experience.
Furthermore, the system is opaque in nature, with significant information asymmetry between patients, hospitals and insurers or TPAs. One such example is that at the time of hospitalization, hospitals are largely unaware of the policy eligibilities of the patient. This necessitates hospitals to submit a claim to the insurer or TPA, who must then manually confirm the patients' treatment eligibility against the policy. These manual processes unnecessarily extend the claims approval cycle time and increase the likelihood of claim rejections due to policy ineligibility even after prolonged wait time, adversely affecting the patient experience. Additionally, the surge in claim submissions merely to ascertain policy eligibility escalates the overall claims processing costs for insurers and TPAs.
On the other hand, the lack of standardized data and processes necessitates substantial manual effort in claim adjudication for both insurers and TPAs. Hospitals often submit claim-related information in unstructured, non-digital formats. The absence of standard guidelines frequently leads to the submission of incomplete claim information, resulting in further inquiries or rejections from insurers and TPAs. Insurers and TPAs need to manually validate each claim prior to adjudication, prolonging the overall cycle time and increasing the costs of claims processing. Additionally, these manual methods are prone to human errors, further escalating overall costs.
Issues with traditional claims management process:
For Patients / Beneficiaries | For Providers | For Insurers and TPAs |
High wait time | Multiple channels of claims processing | Paper based operations using unstructured data |
Negatively impacted healthcare delivery experience | Non-standardized claims workflow | Manual, time consuming and error-prone adjudication process |
Lack of clarity and trust in the claims process | Manual and error-prone paper-based operations | High processing cost per claim |
Increased cost of healthcare and insurance premium | Time consuming and costly process | Lack of quality data to drive further efficiency |
Impacted patient experience |
The NHCX Revolution - A Paradigm Shift in Health Claims Management Process:
The National Health Claim Exchange (NHCX) is a seamless and standardized information exchange protocol released by the National Health Authority (NHA) that facilitates exchange of health claim information between hospitals, and insurers and TPAs.
NHCX is designed to be a single channel of communication for claims management between hospitals and insurers/TPAs. The NHCX gateway facilitates the exchange of claims data between hospitals and insurers/TPAs in a standard interoperable FHIR (Fast Healthcare Interoperability Resources) format. This eliminates the need for multiple channels of communication, streamlining claims processing, and settlement workflows.
A perfect real-life example to describe the NHCX gateway is UPI (Unified Payment Interface). UPI is single channel gateway which facilitates payments across all banks in India. However, UPI does not have any user interface of its own. Both payer and payee need to integrate their own applications with the UPI gateway, through which they will be transferring the money. Once both payer and payee have applications integrated with the UPI gateway, the payment transactions can be processed. Similarly, the NHCX gateway does not have its own user interface either. The hospitals need to use a system which is integrated with NHCX gateway using API (Active Programming Interface). On the other side insurers and TPAs also need to have their systems integrated with the NHCX gateway APIs. Once both sides are connected to the gateway, they can start leveraging the power of this new digital public good.
NHCX aims to bring much needed efficiency, transparency and standardization in the claims management process. This ensures reduced manual effort, higher consistency, lower errors, and ultimately, reduced cost of claim adjudication. Furthermore, faster claims adjudication means minimal wait for claims approval at the hospital, and enhanced patient experience. All these will not only enhance the experience of healthcare for patients, hospitals and insurers alike, but also help enhance trust among each other in the entire ecosystem.
Key challenges faced by the Hospitals and Insurers/TPAs in the Traditional Cashless Claims Management Process, and benefits that the NHCX brings:
Hospitals | Insurers / TPAs |
1. In the traditional claims management process, hospitals are grappled with fragmented information exchanges. Each insurer/TPA maintains distinct portals for claims management, and a few lack a portal altogether, relying solely on email as the communication channel. The process of managing claim approvals and reconciling payments is often cumbersome, adversely affecting the patient experience and hindering efficient working capital management. NHCX introduces a single channel for cashless claims processing across private and Government health insurance schemes. This eliminates the need for multiple channels of communication, streamlining claims processing, and settlement workflows. 2. In traditional claims management process, hospitals cannot verify the patients' policy eligibility by themselves. They need to submit a claim to the insurer/TPA, where the insurer/TPA needs to manually verify the patient's eligibility against the policy. The manual processes lead to unnecessary delays in obtaining claim approval for hospitals. Also, after a long wait time, in case the claim is rejected because of policy ineligibility, it impacts patient experience. NHCX offers enhanced visibility of patients' policy eligibility to hospitals, revolutionizing the claim processing experience for hospitals, patients, and insurers/TPAs alike. The ability to validate treatment eligibility against policy terms and conditions (including exclusions, inclusions, sub-limits etc.) before submitting a claim, provides greater clarity to both patients and hospitals. 3. The claim approval processes in traditional claims management process are opaque and time- consuming. The absence of standardized workflows across insurers and TPAs poses challenges for hospitals in navigating the approval labyrinth, resulting in delays and uncertainties that tarnishes the overall patient experience. NHCX introduces standardized workflows, supported by interoperable data formats, which empower hospitals to navigate through claim approval processes with more clarity, reducing uncertainties and delays. | 1. Traditionally, insurers and TPAs operate within a realm of unstructured claims handling. The absence of standardized data and processes results in significant manual efforts in claim adjudication for insurers/TPAs. Furthermore, such manual processes are susceptible to human errors, leading to a further increase in the overall cost and negatively impacted patient experience (due to high wait time at the hospital to obtain claim approval). NHCX establishes a structured framework for claims handling. Interoperable data formats and standardized processes ensure reduced manual effort, higher consistency, lower errors, and ultimately, reduced costs of claims adjudication. Furthermore, faster claims adjudication means minimal wait for claims approval at the hospital, and enhanced patient experience. 2. Incomplete and improper claims submission in traditional claims management process contributes to multiple back-and-forth communication between hospitals and insurers/TPAs, thereby increasing both claim processing cost and time for insurers/TPAs. NHCX aims to facilitate accurate claim submission by enabling hospital-side claim eligibility validation and specifying mandatory document requirements. This significantly reduces incomplete claims received by insurers/TPAs, thereby decreasing overall claim processing volume, time, and cost. |
IHX’s NHCX Integrated Software: Helping hospitals, insurers and TPAs navigate the future seamlessly
IHX’s NHCX Integrate Software seamlessly integrates with the current IT infrastructure of the hospitals, insurers and TPAs, ensuring compliance with the National Health Authority (NHA) and the Insurance Regulatory and Development Authority of India (IRDAI) guidelines. From expediting claim approval for hospitals to enhancing operational efficiency for the insurers/TPAs, the IHX Nucleus offers tailored benefits for insurers, TPAs and hospitals alike.
Key Benefits for the Hospitals
Today, over 14,500 hospitals utilize IHX Nucleus to manage cashless claims. IHX Nucleus, coupled with the IHX’s Hospital NHCX bridge, ensures hospitals are compliant with the NHCX guidelines, without the need of significant IT investment or maintenance cost, or change in their existing processes.
Moreover, IHX’s NHCX Bridge enabled Nucleus platform can be seamlessly integrated with the HIMS system, allowing hospitals to process claims via NHCX directly from their HIMS systems, thereby driving further efficiency.
Using IHX’s solutions, hospitals can quickly realize the benefits of sending claims via the NHCX gateway, such as:
Single channel cashless claims processing across Government and private health insurances
Better clarity of patients’ eligibility against their insurance policy
Reduced queries and approval turn-around time (TAT)
Enhanced user interface, alerts and notifications for efficient claims tracking and task management
Better patient experience
Apart from delivering the benefits of NHCX, IHX Nucleus also empowers hospitals to streamline their credit business revenue cycle management, offering advanced features such as analytics dashboards, reconciliation, real-time alerts, and more.
Key benefits for the Insurers and TPAs
IHX’s plug-and-play API-based Payer NHCX Bridge Software facilitates insurers and TPAs to achieve NHCX compliance without necessitating alterations to their existing Claims Management System (CMS).
The CMS of insurers and TPAs operate with its own data formats, which are employed in processing and adjudicating claims. Modifying these data formats to align with NHCX’s FHIR standards would entail substantial IT investment and alterations to the core system of the CMS. IHX’s Payer NHCX Bridge functions as a wrapper for the existing CMS. The Bridge manages the NHCX standards and facilitates conversion between FHIR and the CMS’s existing data formats. This approach enables insurers/TPAs to achieve compliance with NHCX guidelines without disrupting their existing infrastructure.
Furthermore, with over 14,000 hospitals using IHX’s Nucleus platform to manage cashless claims, IHX can facilitate insurers and TPAs to swiftly expand NHCX adoption across their hospital network.
IHX helps insurers and TPAs to realize the benefits of processing claims via the NHCX at scale:
Reduced claim volume by enabling better visibility of patients’ coverage eligibility for hospitals.
Single, digital channel of communication for cashless claims processing across the hospital network
No need to manage own hospital side portal for cashless claims processing
Reduced queries and approval turn-around time (TAT)
Reduced cost of claims processing
Better member experience
IHX’s other groundbreaking solutions, such as AI-enabled digitization, adjudication, and investigation engines seamlessly integrate with the NHCX Bridge Software, contribute to further efficiencies in claim processing for insurers and TPAs.
IHX - A strategic partner for healthcare stakeholders, offers a solution that not only meets ABDM-NHCX guidelines but also enhances the overall healthcare ecosystem. By choosing IHX, hospitals, insurers and TPAs can seamlessly adopt new NHCX features, and ensure compliance, improve patient experiences, increase operational efficiency, and reduce costs. Embrace IHX as the catalyst for a seamlessly integrated, efficient, and future-ready healthcare ecosystem.
Author: Swarnendu Chowdhury, Manager - Strategic Initiatives, IHX Private Limited.
Disclaimer: The opinions expressed within this article are the personal opinions of the author. The facts and opinions appearing in the article do not reflect the views of IIA and IIA does not assume any responsibility or liability for the same.
