health insurance used to work on a reimbursement basis in the past. The hospitalisation costs had to be paid out of your own pocket before they could be claimed from the insurance company. Basically, this means paying your hospital bill with cash, getting medical treatment, and then claiming insurance reimbursement.
Unfortunately, most people don't have that much cash on hand or can't arrange it right away. This concern led to the introduction of cashless claims. Under a cashless claim, the insurance company will authorise your claim and pay the hospital directly.
Let’s see how cashless health insurance works in this article.
How Does Cashless Health Insurance Work?
If you want to apply for a cashless claim, you need to get treated in a network hospital listed with your insurance company. If your preferred hospital is on your insurer’s approved list of cashless hospitals, they will settle the medical bills directly with the insurer. You are only responsible for paying any expenses that aren’t covered by your plan.
You don't have to worry about large sums of cash or paperwork. Your insurance company and the hospital will take care of the entire process.
Step 1: Verify If Your Policy Covers Cashless Payments
You should ensure that the hospital at which you are seeking treatment has a tie-up with your insurer. The best thing would be to carry a copy of your policy and obtain confirmation from the hospital.
Ask the hospital desk for a list of all the documents they will need from you. You can also check your policy for any sub-limits for certain illnesses. By doing so, you will know how much you will be responsible for paying from your own pocket.
Step 2: Pre-Authorization
Pre-authorization is the process wherein the hospital asks the insurance company to approve the treatment costs initially. During this step, you'll be required to fill out and sign a claim form. Your doctor or hospital staff will also fill a part of it.
As soon as the insurance desk receives the request, they will take the process ahead with a third-party administrator (an outsourced agency for processing claims) or the insurance company.
Step 3: Advance Deposit
Unlike your insurance company's call centre, the hospital's insurance desk may not be available all the time. Due to that, you might need to pay an advance for admission or postpone discharge if the final approval takes a long time.
Sometimes, the hospital may require an advance payment from you if the treatment cannot wait for pre-authorization approval. Once the cashless claim request is approved, the advance will be refunded - either fully or partially.
Be prepared for such situations by keeping emergency money or an active credit card handy.
Step 4: Documents To Submit
The insurance desk may ask you to submit certain documents such as -
- Policy copy or cashless card
- Medical records from all past hospitalizations
- KYC for the patient
- Police FIR (in accidents)
Step 5: Follow-Up And Tracking
Get All The Paperwork Ready In Advance
For planned hospitalizations, submit the form 3-4 days before admission, so there are no last-minute hassles.
In case you are the patient, you can ask a family member to finish the paperwork before you get to the hospital - to avoid unnecessary delay.
In case of emergency hospitalisation, submit the form within 24 hours of hospitalisation.
Track The Progress
As soon as you submit the pre-authorization form, you will be able to track the process on the TPA app or website.
Respond promptly to insurer enquiries, in order to avoid a delay in claim settlement. The insurance company can revoke the authorization in case they don't receive a proper response or documentation. In that case, you may have to seek reimbursement.
Take Soft Copies
You might be asked to submit original copies of bills and other documents to the insurance company. Hence, make sure you have a soft copy of every document you submit, as it might be difficult to retrieve later.
Keep Track Of All Pre-Hospitalization Costs
Medical expenses incurred prior to hospitalisation must be claimed separately from the insurer. So, keep all original prescriptions, bills/receipts, and reports (including films) that led to the hospitalisation because they can be claimed separately. Additionally, it's crucial to have the prescriptions written by the first doctor you saw regarding the issue that prompted your hospitalisation - particularly if they come from a different hospital or clinic.
Step 6: Final Billing
After the doctor finalises the discharge date, follow up with the hospital insurance desk to submit all your final paperwork, including the final bill and discharge summary. The process can take some time, so it is important to begin as soon as possible.
Your insurance company will notify you at this stage if any documents are pending. Track progress online with the insurance company, and submit any missing documents as soon as possible.
Once all the papers have been submitted to the insurer, final approval usually takes 2 to 6 hours. If you don't get final approval or it takes longer than expected, you may have to keep the patient waiting at the hospital or make the payment upfront and claim reimbursement later on.
Step 7: Claim Approval
All the details of the claim settlement will be included in the claim settlement summary. It will include a list of approved and unapproved expenses as per your policy terms and conditions.
You will not be required to foot any approved expenses. They will be paid directly to the hospital by the insurance company.
Any expenses not approved will be reflected on your bill and you will be liable for them. This may include co-payment, proportionate deduction, consumable costs, etc. You should make sure that your initial advance is adjusted in this calculation.
Hospitals may retain some deposit money after discharge until they receive the payout from the insurer. Make sure you keep this receipt and set a reminder to collect this refund in a couple of months. Also, any pre-hospitalisation and post-hospitalisation expenses can be claimed on a reimbursement basis.
Having cashless health insurance ensures convenience since you don't have to chase after the insurance company for reimbursement. Everything is handled by the hospital and the insurance company. However, please read the terms and conditions associated with the cashless process – so you don’t get caught off guard at the time of claim.