Does your medical bill have more diagnostic tests than needed? Is your hospital stay or doctor visits longer than warranted? Help is at hand from a company that has objective guidelines that help track such excesses, which are often cause disputes between hospitals and health insurance companies.
Milliman a global actuarial company has launched ‘claims processing guidelines’ that enables a third party administrator (TPA) or insurer to determine the severity of a patient’s condition and identify if the length of hospital stay, investigations, consumables and treatment procedures are more than what is typically required.
Known as “ClaimRef,” the rule-based product which can be linked to software, is based on Indian evidence of expected medicinal practices patterns for 125 common conditions that run up high costs.
Insurers have been demanding that TPAs, who process hospitalization claims, do more to identify unwarranted billing as the
overall claims ratio (the ratio of the cost of claim to the premium paid) for the industry in health insurance continues to hover around 120 per cent for 2007-08.
“The tool also tries to reduce the areas of frequent disputes between insurers and hospitals. For example- hospitals include anesthetist’s fees for procedures where a surgeon himself could have provided anesthesia. The product tells a TPA under what conditions an anesthetist is required,” says Alam Singh, assistant managing director at Milliman’s Indian unit.
Milliman says an insurance company will save 9 per cent per policy by using its tool.
Similar initiatives have been taken by Pune-based Armed Forces Medical College (AFMC) who has designed guidelines for 35 clinical conditions.