Emerging Project Lessons
Health care providers who are new members of the network tend to overcharge patients availing cashless facility. Though envisaged as a cashless scheme for the beneficiaries, almost 80 per cent of the claims were being paid as reimbursements, even at network hospitals. Patients were offered “loans” by the federations to help them make payment to the hospitals that could be paid back when reimbursed by the insurer. One reason for the lack of cashless claims was that when patients informed that they were covered under an insurance scheme, the rates they were offered were different from the ones when they paid cash. It is possible that the hospitals that were new members of the network were unsure of the time it would take to get money from the insurer or TPA, and hence were compensating by charging a higher rate to patients. This points to the need to educate hospitals about the process when they are included in the networks. This needs to be further investigated.
Date of last Learning Journey update: June 2011