Health Insurance

What is a Network Hospital? How Are They Different From Non-Network Hospitals?

What is a Network Hospital? How Are They Different From Non-Network Hospitals?

While researching and understanding health insurance, if you’ve heard this word “Network hospitals” and wanted to know what this is all about, you have reached the right place.

To understand network hospitals better, we need to get some basic understanding of health insurance claims.

So you can make a health insurance claim in two ways: Cashless Claim and Reimbursement Claim.

In a cashless claim, the insurance company settles your approved medical bills directly with the hospital you’ve been treated at.

On the other hand, in a reimbursement claim, you’re required to pay the expenses out of your own pocket and then claim a reimbursement from your insurance company.

Looking at these two options, it is quite obvious that the preferable choice for anyone would be a cashless claim, since medical bills can be quite big! You also don’t have to worry about the documentation, this too is managed by the insurance company and the hospital.

So, how can you be eligible for a cashless claim? By getting treated at a network hospital.

Yes, that’s where network hospitals come into the picture

Now, what is a network hospital and how does the cashless claims process work? What is a non-network hospital? Which is the better choice?

Let’s have a look!

What Is A Network Hospital?

A network hospital is a hospital that has an agreement with your insurance company for providing cashless treatment. These hospitals are listed by either the insurer or the third-party administrator (TPA) of the insurer, to facilitate cashless claims.

Insurance companies and hospitals basically enter into a contract for providing cashless facilities to the customers. The contract will mention the process that both the insurer and the hospital need to follow to process the claims, and often pre-agreed rates for various treatments and packages.

The contracts will include -

How the documents will be sent to the insurance company for approval from the hospital.

The set of documents that will be sent.

The time the insurer will take to process the cashless request, etc.

Pre-agreed rates for various treatments carried out at the hospital.

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What Is The Process Involved To Get Treated At A Network Hospital?

If you are getting hospitalised in a network hospital and opt for a cashless claim, first inform the insurer about your hospitalisation and receive a prior approval called “pre-authorization” through your hospital.

  • Planned Hospitalisation

    Make sure you inform your insurer beforehand if you're planning on getting hospitalised so that the pre-authorization process is completed before you're admitted. For instance, if you have planned a procedure like a gallbladder surgery, let your insurance company know before the treatment begins through the network hospital.

  • Emergency Hospitalisation

    If you’re admitted to a network hospital in an emergency situation, for instance, injuries because of a road accident, the claim intimation is sent to the insurance company by the cashless desk of the hospital.

    Keep in Mind: The insurer may first approve an initial lower amount and each time the hospital's total bill surpasses the approved amount, the hospital can make additional requests to the insurer to increase the limit approved under pre-authorization.

Once your discharge date is finalised, the final bills and requisite documents will be sent to the insurer by the hospital insurance desk/TPA. The insurer then evaluates and approves the same, after which the amount is settled directly with the hospital.

Are Network Hospitals Permanent?

Network hospitals do not have to remain on the insurance company's list permanently. Removing the hospital from the insurance company’s network is at the insurer’s discretion. The same applies for the hospitals as well and they can step out of the signed contract anytime.

Insurers might stop providing cashless facility to a certain hospital due to reasons like -

  1. Fraudulent claims from the hospital, or
  2. Multiple violations of the contract terms.

Some hospitals may not accept cashless claims even if they're listed with your insurer due to many reasons, like -

  1. Fraudulent claims from the hospital, or
  2. Too many negotiations done regarding payments
     

How To Find Whether Your Hospital Is Under The Network Hospitals List?

All insurers provide a list of network hospitals with the health cards given to you. You will also find these details on their website.

You can check if your hospital comes under the insurer's network hospital list by following the below steps -

Visit your insurer’s website.

Enter your city name or pincode and type your hospital's name in the search bar.

If the hospital is listed with your insurer then you will find its name on the list.

You may also call the insurer toll-free and check the same.

For example, If you have a Niva Bupa policy, you can visit their website and go to the top of their homepage where you will find an option "Hospital Network”. After clicking on it, you will be directed to a page where you will be asked to enter your city and the hospital name. Once you enter the details, if your hospital is present in their network list, it will be displayed on the screen along with their address and contact details.
 

Should You Confirm With The Hospital and Insurer About The Cashless Facility Before Getting Admitted?

In case of planned hospitalisation, it is advisable to check with your insurer as well as the hospital about whether the hospital chosen by you will provide a cashless facility. It is important to do this because, as mentioned earlier, sometimes both the insurer and the hospital may refuse cashless claims for a variety of reasons even if the insurer has a tie-up with the hospital.

What is A Non-Network Hospital?

A non-network hospital is one that is not listed with your insurance company for cashless claim settlements.

How Does The Claims Process Work In A Non-Network Hospital?

The claims process for non-network hospitals can be quite laborious and lengthy.

If you get admitted to a non-network hospital, you can’t make a cashless claim. You will have to pay the medical bills yourself and then get them reimbursed by your insurance company. This becomes even more stressful when the expenses are high and you have to run from pillar to post to arrange the money.

Secondly, there is a lot of paperwork involved. You need to submit all the necessary documents to the insurer to claim a reimbursement. These include -

  1. A discharge summary
  2. Doctor's prescriptions
  3. Original reports
  4. A duly filled out claim form that is stamped and signed by hospital officials.

Make sure you’re super diligent about the documentation, since everything will be minutely checked by the insurer and will determine your reimbursement amount.

It takes at least 10-12 days for the insurance company to cross-verify your bills and then, reimburse your money. Sometimes, the reimbursement can take up to a month to reach your bank account.
 

A Quick Comparison Of Network And Non-Network Hospitals

Parameter Network Hospitals Non-network hospitals
Definition Hospitals enlisted with your insurer that offer cashless facilities. Hospitals that are not listed with your insurance company.
Claims process Directly settled between the insurer and the hospital. Only those expenses not covered by your insurer will have to be paid by you. You need to pay the hospital bill out of pocket, and then claim reimbursement from the insurer.
Waiting Period No waiting period. The insurance company will settle your bills directly with the hospital after it approves your claim. It will take at least 10-12 days for your insurer to settle your claim. Depending on the insurer, the waiting period may vary.
When it comes to settling claims, how easy is it? All the necessary documents such as hospital bills, prescriptions, indoor case papers, etc. shall be submitted by the hospital’s TPA desk directly to the insurer. Once the claim is approved, the insurer will settle the claim directly with the hospital, which eliminates unnecessary delays. The process can take a while to complete. You will need to gather all the documents and bills, submit them to your insurer, then wait for a few days or even months for the reimbursement to reach you.

 

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So, What’s The Better Option?

It is unquestionably better to pick a network hospital for your treatment as it will spare you the time and effort of gathering paperwork and filing claims. You won't be responsible for paying huge hospital bills out of pocket as the insurer shall directly settle them with the hospital.

Opt for a non-network hospital only if -

Your insurer's network hospitals don't offer the treatment you need, or

You face a medical emergency. In this situation, getting admitted to the nearest hospital is crucial, regardless of whether it is a network hospital or a non-network hospital.

Summing Up!

We hope you now have a clear understanding of what network hospitals and non-network hospitals are. When choosing a health insurance plan, make sure the insurer supports a large number of network hospitals. Opt for non-network hospitalisation only in case of emergency or when the required treatment is not available in any of the network hospitals.