NEWS – The Health Ministry and the Insurance Regulatory and Development Authority of India (IRDAI) are collaborating to launch the National Health Claim Exchange (NHCX)

HIGHLIGHTS

Overview of Current Claim Processing

• Insurance Card Usage: Patients currently present insurance policy details or cards issued by TPAs or insurance companies at hospitals.
• PMJAY Beneficiaries: PMJAY beneficiaries receive cards from State Health Agencies (SHAs).
• Claim Processing Portals: Hospitals use specific portals for claim documentation and approvals.
• Manual Process: Current claim processing is largely manual, unlike auto-adjudication in developed markets.

Challenges of Current Process

• Lack of Standardization: Claim exchange lacks standardization across the ecosystem.
• Manual Data Exchange: Most data exchanges occur through PDFs or manual methods.
• No Health Standards: Absence of established health standards leads to varied processes among insurers, TPAs, and providers.

National Health Claim Exchange (NHCX)

• Communication Protocol: Facilitates seamless exchange of health claim information among payers, providers, beneficiaries, and entities.
• Interoperable & Machine-Readable: Designed to be interoperable, machine-readable, auditable, and verifiable.
• Open Standard: NHCX is based on open standards, aligning with IRDAI’s ‘Insurance for All by 2047’ goal.

Expected Impact

• Standardized Healthcare Pricing: Platform promotes uniform data presentation and centralized validation, leading to standardized healthcare pricing.
• Efficiency & Transparency: Improves efficiency, predictability, and transparency in healthcare costs.
• Reduction in Administrative Burdens: Centralizes health claims, reducing administrative burdens on hospitals using multiple portals.

Incentives under NHCX

• Digital Health Incentive Scheme (DHIS): Introduced to promote digital health transactions and incentivize hospitals.
• Financial Incentives: Hospitals receive financial incentives for insurance claim transactions through NHCX.

Reasons for NHCX Implementation

• Study Insights: Study highlights the importance of health insurance in reducing out-of-pocket expenses and providing healthcare services.
• Hospitalization Cases: Cases vary across private insurance, government-funded schemes, urban, and rural areas.
• Challenges: Improving relationships between hospitals and insurance companies, addressing issues like discharge delays and miscommunication.