Was your mother under the influence of alcohol?

About eight years ago when I wrote in Express Healthcare Management about the need for electronic claims processing standards for India, (http://www.expresshealthcaremgmt.com/20021015/medtech1.shtml) little did I know that questions like these could mean endless struggles for patients grappling with the beauty of insurance claims processing in India.

In my article in 2002, I made the case for a standards based claims processing system modeled on HIPAA standards, than trying to re-invent the wheel. Not sure how many healthcare managers paid attention that story in 2002. Health Insurance was in its infancy. Today claims processing worries have come to the fore front of the healthcare executives' agenda.Not sure if the patients concerns are being heard…

Today I am writing, not as a healthcare management consultant, but as an ordinary citizen, handling his mother’s hospital admission in a reputed hospital in India, frustrated working with the health insurance unit in the hospital, faxing and re-faxing documents coupled with several calls to the TPA across various cities, listening to a wide variety of “the put on hold” music etc.

I tried my best to go through the painful experience and not pull strings/use short cuts, because I wanted to endure the whole process as a lesson learnt in a patient’s experience with claims processing.


Now going back to whether my 65 year old mom involved in an accident was under the influence of alchohol …. This was a question on one of the forms provided by the TPA and had to be completed by the doctor. The doctor had omitted this question, because she did not think this was a relevant question. Unfortunately the hospital’s insurance cell which has been working for several years with TPAs did not cross check the form prior to faxing it to the TPA. A few days hence, the TPA rejected the claim that came in an incomplete form. From then on it was a back and forth of discussion with doctor who did not want to fill the form again, to more detailed documentation requirements from the TPA. This was just the beginning; wrong address on the hospital admission form, wrong age on the record; we had a cocktail of issues to sort out leading to endless calls and faxes… I was even thinking this could be the plot for a Hindi movie.

My intent is not to blame the TPA or the sympathetic but untrained insurance clerks at the hospital. The entire system around health insurance in India needs a revamp; claims processing challenges are only a symptom of a health insurance system that is ill. However issues with claims processing have major implications that can cripple the progress of insurance adoption in the country.

Even with my back ground,if I found navigating claims processing a nightmare, one can imagine what an ordinary patient, often illiterate has to endure to make cashless insurance processing a reality.

It was also a lesson that could be useful in our start up organization, health FIRST Hospital Network. For me it was a grim reminder that transferring best practices to the Indian healthcare sector is not as easy as it seems on slicks presentations and that India shining is a long way off atleast in healthcare sector.


Shall be writing about some of the issues with claims processing and TPAs in my next blog.