Implement EMRs for smooth claims: IRDAI

Chennai: The absence of digitised records in a majority of the hospitals in India is reported to have  resulted in claims getting delayed more often than not. Those that do have electronic medical records (EMR), have no uniformity of coding, running claim settlements into difficulties again.

To tackle this, the Ministry of Health and  the Insurance Regulator Development Authority of India (IRDAI)  have been promoting the use of ICD-10, an international system for medical coding.

The proposal, however, has yet to take off. Further adding to the issue is that, though having been made mandatory by the Indian Medical Council for Research, only a few corporate units have taken it on, reports  TOI.

"The problem in India is we have a regulator for insurance and not for health. If hospitals across India implement ICD-10, the claims settlement process will be faster, cutting the turnaround time to half," said an IRDAI official. ICD-10, which allows for more than 14,000 codes for diseases, symptoms, abnormal findings and injury.

Both state government hospitals and charitable institutions have yet to implement ICD-10. ‘The concept of an IT department in a hospital, founded on principles of social welfare, is quite foreign even today," added an official.

According to observations made many a times  claims gets held up due to ambiguity on coding and treatment procedures, despite initial promises of instant cashless settlements.

"Doctors, paramedics, hospital staff are not well versed with coding. So if there is a patient with kidney problems, high levels of creatinine and inflammation of the skin -what could happen is that the doctor knowing the code for renal problems will jot that down, but leave out the inflammation of skin, if he didn't know the code. The inflammation of skin could have medical significance later, but gets missed. Improper coding, results in ambiguity when it comes to claims settlement," said Nikhil Apte, Chief Product Officer, Product Factory (health insurance), Royal Sundaram Alliance Insurance Co Ltd.

Sandeep Patel, CEO, Cigna TTK Health Insurance Co,  elaborating on procedural hindrances said that corporate hospitals with IT facilities were also found scanning documents and pushing them ahead, as staff  was not trained for the job, making it a manual procedure again.

"Doctors, paramedics, hospital staff are not well versed with coding. So if there is patient with kidney problems, high levels of creatinine and inflam mation of the skin -what could happen is that the doctor knowing the code for renal problems will jot that down, but leave out the inflammation of skin if he didn't know the code. And the inflammation of skin could have medical significance later, but gets missed. Improper coding results in ambiguity, when it comes to claims settlement," said Nikhil Apte, chief product officer product factory (health insurance), Royal Sundaram Alliance Insurance Co Ltd.

Another  insurers grouse  is that even with corporate hospitals that have invested in IT, documents are merelyscanned and sent for claim settlements. "It again becomes a manual procedure. We can't even do a simple Ctrl+F search function," said Sandeep Patel, CEO, Cigna TTK Health Insurance Co.

The insurance industry bigwigs claim that EHRs would make for better services. "All hospitals across the country are expected to follow the ICD10 coding. However, our observation is that only the hospitals accredited by National Accreditation Board for Hospitals and Healthcare Providers (NABH) and Joint Commission International (JCI) follow the ICD10 coding. For various treatments and surgical procedures - procedure coding system (PCS) is used," said Abhijeet Ghosh, Head - Health Administration Team, Bajaj Allianz General Insurance.

According to Ghosh, insurers  have constantly endeavoured to encourage network hospitals to follow EMR procedures, for they ensure seamless transactions,  enhancing the overall claim experience of patient clients.