National Health Claim Exchange

10.06.2024

National Health Claim Exchange

Why in the news?   

           The Health Ministry along with the IRDAI are launching the National Health Claim Exchange (NHCX), a digital platform which will bring together insurance companies, healthcare sector service providers and government insurance scheme administrators.

About National Health Claim Exchange (NHCX)

• It is a digital platform which will bring together insurance companies, healthcare sector service providers and government insurance scheme administrators.
• It aims to enhance efficiency, transparency, and accuracy in claims processing by facilitating the exchange of health insurance claims data among various stakeholders, including payers, providers, beneficiaries, regulators, and observers.
• The integration with NHCX is expected to enable seamless interoperability of health claims processing, enhancing efficiency and transparency in the insurance industry, benefiting policyholders and patients
• The NHCX aligns with the goals of the Ayushman Bharat Digital Mission, which aims to simplify the health insurance claims procedure and create a unified digital platform for healthcare services.

Why is NHCX being brought in?

• A paper titled ‘Health Insurance Coverage in India: Insights for National Health Protection Scheme’ highlights the importance of health insurance in providing healthcare services and reducing high out-of-pocket expenses.
• The paper notes that hospitalization cases are highest for those with private insurance (54.4 per 1, 00,000 persons) overall.
• Urban areas seeing the highest cases under government-funded schemes (60.4 per 1, 00,000 persons), and rural areas experiencing higher cases for private insurance purchases (73.5 per 1, 00,000 persons).
• Urban areas generally have higher in-patient cases compared to rural areas.

Challenges of the NHCX

• Improving the relationship between hospitals and insurance companies
• Health insurance accounts for about 29% of the total general insurance premium income in India.
• The main challenge is improving the relationship between hospitals and insurance companies, which requires digitization efforts, IT system upgrades, and workforce training.
• Other issues: Issues like discharge delays and miscommunication that complicate matters.
• Building trust among policyholders depends on efficient service delivery.

Current Claim Processing

• Currently, patients provide their insurance policy details or a card issued by a Third-Party Administrator (TPA) or insurance company when visiting a hospital.
• For Pradhan Mantri Jan Arogya Yojana (PMJAY) beneficiaries, the card is issued by the State Health Agency (SHA).
• Hospitals access specific claim processing portals to upload necessary documents for preauthorization or claim approval.
• The State Health Agency, insurance company, or TPA authenticates and digitizes the form using their internal portal, and the claims are adjudicated by the relevant team.
• In India, much of this process is manual, unlike many developed markets where over 90% of claims are auto-adjudicated.

Challenges of the Current Process

• The current process of exchanging claims lacks standardization across the ecosystem.
• With most data exchange occurring through PDF/manual methods.
• Additionally, there are no established health standards.
• Processes vary significantly among insurers, TPAs, and providers.

                                                                        Source: The Hindu

Ques :- Consider the following statements with reference to the National Health Claim Exchange:

Statement-I

It is a digital platform which will bring together insurance companies and healthcare sector service providers.

Statement-II

 It aligns with the goals of the Ayushman Bharat Digital Mission, which aims to simplify the health insurance claims procedure.

Which one of the following is correct in respect of the above statements?

1. Both Statement-I and Statement-II are correct, and Statement-II is the correct explanation for Statement-I.
2. Both Statement-I and Statement-II are correct, and Statement-II is not the correct explanation for Statement-I.
3. Statement-I is correct, but Statement-II is incorrect.
4. Statement-I is incorrect, but Statement-II is correct.

Answer A