Hospitals need a more professional approach while preparing and sending documents to insurance companies for clearance, doctors should be asked to write the discharge advice on time and insurance companies need to be more precise while verifying documents and not make unnecessary queries that delay discharge.
These are some of the steps that can help overcome shortcomings of hospitals and insurance companies so patients with cashless health insurance need not wait for many hours after discharge.
Metro reported on Friday how patients are inconvenienced as they have to wait for six to seven hours to go home even after discharge because the clearances take so long.
Several officials of private hospitals and insurance companies pointed out some of the problem areas.
Preparing documents
According to hospital officials, the documents for discharge should be prepared carefully with detailed information and sent to the third party administrator (TPA) or the insurance companies as early in the day as possible to avoid delays.
“We have seen that when the documents are sent early in the day, before noon, and with detailed information, the clearance comes faster,” said Sudipta Mitra, chief executive of Peerless Hospital.
“So, the hospital staff should prepare the documents from day one of admission. As soon as the doctor advises discharge, they can quickly prepare the final documentation and send it to the insurance company with minimum errors,” he said.
“We request doctors to write the advise for discharge the night before so the final documentation is prepared and sent to the insurance company early the next day. Otherwise, there is a backlog.”
A TPA official said they clear claims for cashless insurance on a “first-in-first-out” basis. “Usually, the cases pile up in the later part of the day and so, the documents sent later get delayed,” the official said.
Lack of detail
Insurance companies and TPAs alleged that often there is lack of information in documents they receive from hospitals.
“Often, the approach is lackadaisical and the documents lack basic detail,” said an insurance company official.
Claims are easier to settle for surgical cases, he said.
“But for medical management cases, there is need for very detailed documentation. History of the ailment and detailed notes on the condition of the patient when brought to the hospital in case of emergency are extremely important. Often, we find just one sentence written where it is stated that the patient is referred to orthopedics, neurology or some other speciality department,” said the official.
Evaluations, test results, final diagnosis and the line of treatment should be mentioned in detail, he said.
Role of doctors
Doctors should try to advise discharge either the night before or early in the day, said a hospital official.
“The problem is with visiting consultants who often come late in the afternoon and discharge a patient,” said the CEO of a hospital.
“The problem is more acute with smaller nursing homes who have less control over the doctors.”
A TPA official said one major cause of delay in final clearance is waiting for replies from treating doctors.
“Usually, we want a reply to a query from the treating doctor and not his or her assistants. But there are inordinate delays at times in getting replies,” the official said.
A hospital official said in case of surgeons, if the doctor is performing a surgery, it can take hours for him or her to be available to reply.
“Insurance companies have to be less rigid and allow a member of the treating team to reply to queries,” said the hospital official.
Queries
An elderly patient was recently admitted to a hospital off EM Bypass with respiratory distress.
“The initial diagnosis was lower respiratory tract infection but later, tests revealed he was suffering from urinary tract infection. The insurance company sent a query whether UTI is related to smoking, which it is not,” said the hospital official.
Hospital officials said often, insurance agencies and TPAs raise irrelevant queries, leading to delays in discharge.
“This is a problem,” admitted a TPA official. “This is because often a set guideline is followed while evaluating a case”.