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Some Unknown Factors that Delay the Claim Settlement Process

Published On Jan 17, 2020 5:30 AM By Prashant Srivastava

Are you feeling disappointed because of late claims settlement process from the insurer? Do you think insurance company often delays in approving your claim?

Didn’t you get cashless treatment when you were hospitalised last time?

Are you wondering what makes insurance companies delay in approving claims?

Not all the times are health insurance providers late in approving a claim. But when they do, you become helpless as your hospital will refuse to discharge you until or unless the insurance company signs off on the bills.

This is an unwelcome move. But many insured patients who make cashless claims have to experience this. Despite pre-authorization has become easier and quicker, claims settlement at the time of discharge sometimes become a long and cumbersome process.

Who is to blame for this?

Keep reading to know the answer.

The Insurer Is Not Always Guilty

You can’t just blame your insurer for the late claim approval. Usually, insurance claims are delayed because there is no single point where claims can be verified.

Medical day-care centers and hospitals are not listed on one platform. Due to this, insurance claims process gets delayed.

At a time, when everything is getting digitized, exchange of medical records between insurers and hospitals should be seamless.

Also, read 4 Easy Ways to File a Complaint Against Your Health Insurance Company

When it comes to cashless claim, insurance companies are generally the faceless entity because you directly deal with the health insurance desk of the hospital. In such a situation, you may think that the insurer is taking too much time to settle bills. You scarcely realize that your hospital too could be delaying the process.

Pre-authorization Is The First Step

Pre-authorization is the first step towards cashless claim settlement. The steps of filing a claim include:

  • Getting a pre-authorization form from the insurer or the hospital desk
  • You need to fill in the personal and insurance policy details
  • The treating doctor has to fill in details about the treatment
  • Then the form is sent to the hospital’s billing department
  • The billing department gives an estimate of the cost
  • Then the form is sent to the insurance company along with the documents
  • The insurance company reviews these documents
  • After the review, they pre-authorize the claim

The term ‘pre-authorization’ commonly means the insurer has sanctioned an initial amount with an acknowledgement that it (insurer) will pay the claim subject to the final invoice received from the hospital.

Therefore, it’s important to keep in mind that a pre-authorisation is just an acknowledgement. It nowhere guarantees that the claim will be settled. Even if your claim is pre-authorized, the insurer may ask the hospital for additional documents later. The approval for them could consume time.

In case of an unplanned or emergency admission, the hospital can ask you to deposit an amount. However, this amount is reimbursed later. This is done as the admission in the hospital is sudden and you don’t have time enough to go through the pre-authorization process.

On the Day of Discharge

Although pre-authorization is a quick process, settling a claim on the ‘discharge day’ could be a time-taking and cumbersome process. Here are a few steps taken by the hospital and the insurance company.

  • To process the claim, the insurer needs the discharge summary from the hospital
  • The hospital sends the discharge summary and hospital bills to the insurer
  • This process may take time depending on how fast these details are sent by the hospital to the insurance provider
  • Once the details are received by the insurer, it scrutinizes the bills and then settles them

It’s important to note that it is the hospital that works preliminary on the final bill settlement. Hence, the insurance company or Third Party Administrator (TAP) gives their final nod to the hospital to process the settlement.

In some cases, hospitals are responsible for submitting irrelevant documents or bills to the insurance company for authorization which leads to late settlement.

It’s also essential to keep in mind that the claim settlement process majorly depends on the administrative efficiency of the insurance company and the healthcare provider.

At Your End

To speed up the claim settlement process when you or any insured person from your family is hospitalized, it is important for you or the accompanying person to do:

  • Check with the doctor for a possible date of discharge
  • Request the doctor to tell you the time of discharge
  • Inform the insurance help desk at the hospital and ask them to prepare all the relevant documents
  • Tell them to send all the relevant documents to the insurer immediately when the discharge is ordered
  • Don’t fail to keep calling the insurance company or the TAP to check the status and fast-track the process

Even in the best hospitals, 7-8 hours of wait time can take for claims approval and discharge. A proactive approach can ensure your claim is settled and you get discharged quickly and easily.

Also Read

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