TECHNICAL FIELD:
The present disclosure relates to a method for Pre-Authorization of the assured benefits, generated
at the hospitalization end at the point of service transaction terminal , and more particularly, to a
method for generating the Pre-Authorization for the assured benefits within a few seconds using an
access card at point of service transaction terminal at the time of admission of customer (patient) and
providing a payment settlement at the point of service transaction terminal at the time of discharge.
BACKGROUND:
Pre-Authorization process for approving the Health benefits under employers/insurers schemes has
been prevailing over three decades world wide and about a decade in India. Though there is substantial
technological advancements however for complexity of health benefits administration over 90% of
process is dependent on Fax machine/ Fax module interface while 10% use internet website to transmit
information at both ends. The said process takes a few hours to over a day at times.
The current market research reveals, 34% of health care expenditure in India is by way of health
care financing schemes, that's when the insurance penetration level is less than 15% which includes
CGHS, ESI and Railways. It is believed that the percentage share shall increase significantly with the
increased insurance penetration in the country. The break-up of the 34% is further bifurcated as 7% self
Insured, 12% ESI/CGHS, 10% others/PSG Self Management Scheme, 5% Government Mass-Scheme.
Though the Cash Less service under insurance and other referred schemes here above have
stabilized to a large extent however the customer expectation has also increased with the time.
Unfortunately there is no significant progress towards product evolution as most of the products in the
market are different variant of age old vanilla "Mediclaim" policy that was introduced in 1986 and
revised in middle of 90's. The very nature of the prevalent product is failing to win the confidence of
the insuring population at large which is considered a barrier for faster growth of the health insurance
in the country.
The experience of availing the Cash Less facility at hospital also differ from person to person and
there are situations that it takes more than 24 hours while 4 hours is considered reasonable time to get
through the process and have clearance for the treatment. At times delays in cash less add to the cost of
treatment with additional day of hospitalization.
The average credit realization period for hospitals remain in excess of 50 days against the agreed
21-28 days for corporate hospitals while for unorganized sector providers its averages beyond 60 days.
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As a result most hospitals have built a finance cost of administration to follow up for payment and both
put together the hospital tariffs are jacked up by approximately 15%. Though the RTGS and NEFT has
brought in some dynamism in the payment mechanism but both does not suit the very requirement due
to time gap in execution of payment, realization reconciliation as customer may not wait at the hospital
at the hospital counter.
US 2007/0005402 discloses a system and method for paying health care charges from multiple
source of payments. The patient first seeks treatment from a provider and then provides the
presentation instrument or card at the point of service terminal where the patient's treatment charge is
to be processed. While the disclosed system does nothing to substantially improves the delay in settling
the balances due at the time of discharge.
US 6,208,973 discloses a point of service third party adjudicated payment system and method
which provides for the creation of an adjudicated settlement transaction at a point of service which
designates the portion of the service to be paid by the third party payer and the portion to be paid by the
customer. The point of service terminal includes an internet connection to a node containing an internet
merchant bank which is to process the credit card transaction via a credit card network in a
conventional manner. However, diis process is not only for credit card but also for Bank Account and
Internet Banking. The adjudication is completed within seconds of an interactive claims submission
and setdement reached within a day or two. However, no technique for adjudicating the claims at the
point of service transaction terminal at the time of admission is disclosed. For an individual provider,
the delay in receiving such payments can be a significant burden.
US 2012/0215553 discloses a method and system identifying health care providers who are
authorized to submit health care claims to health insurer or claims processor. The invention discloses
algorithms to compare information from provider's credit card terminal to information by insurance
company and identifying beneficiaries and dependents who are eligible to receive services capturing
health care encounter at point of service, and capturing location and time of health care encounter of
authorized beneficiary or dependent at the authorized location of a provider. Many a times the service
provider are unable to confirm the permitted charge until after a claim is submitted and adjudicated by
the third party administrator or Insurer.
WO 2012/174643 discloses a method of claim adjudication by online submitting a claim by service
provider at an adjudicators website. The service provider inputting data required by online prompts.
Real time online analysis and adjudication of input data and claim to determine if claims meet the
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adjudicator's preselected criteria. If the claim is accepted, payment is received at a point of sale
terminal by inputting the card multiple times at the point of sale terminal to receive multiple payments
from multiple sources. The recent proliferation of web portals has made it easier to commit fraud and
abuse. Since claim information sometimes only requires a legitimate insured identification such as
social security number for medicare recipients , researching that information on web portals as made
false claims easier to file and be paid.
A method for availing cashless benefits is desired which eliminates delay in settling the
balances due at the time of discharge and providing a pre-authorization of the assured benefits,
generated at the hospitalization end at the point of service transaction terminal at the time of admission
of a patient. Further, there still remains in the art a need for solving the problems associated with fraud
and abuse in health care services. The present invention has been designed to meet mese great need in
the art.
SUMMARY:
An aspect of the present disclosure provides a method for cashless transaction for availing
hospitalization benefits comprising: entering access card information into a point of service transaction
terminal for initializing cashless transaction; entering and storing hospitalization information on the
storage medium of the terminal; transmitting the hospitalization data and the access card data to an
adjudicating element provided by a third party administrator or Insurer ; computing the hospitalization
data and the access card data for determining eligibility and authorizing a value of amount for availing
the hospitalization benefits; electronically storing the value of amount to the access card for spending at
the terminal; inserting the access card into the point of service transaction terminal after availing the
hospitalization benefits for enabling the card reader to read the stored nature of amount, deduct the
portion of value of amount spent on providing hospitalization benefits and electronically storing the
unspent value of amount; and electronically re-transmitting the unspent value to the third party
administrator or Insurer in a predetermined time.
These and other features, aspects, and advantages of the present subject matter will become better
understood with reference to the following description. This summary is provided to introduce a
selection of concepts in a simplified form. This summary is not intended to identify key features or
essential features of the subject matter, nor is it intended to be used to limit the scope of the subject
matter.
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BRIEF DESCRIPTION OF DRAWINGS:
The above and other features, aspects, and advantages of the subject matter will be better
understood with regard to the following description, and accompanying drawings where:
Figure 1: Process Flow diagram for Cashless Authorization.
Figure 2: Process Flow diagram for Payment to service provider.
DETAILED DESCRIPTION:
The present disclosure provides a method for cashless transaction for availing hospitalization
benefits comprising: entering access card information into a point of service transaction terminal for
initializing cashless transaction; entering and storing hospitalization data on the storage medium of the
terminal; transmitting the hospitalization data and the access card data to an adjudicating element
provided by a third party administrator or Insurer ; computing the hospitalization data and the access
card data for determining eligibility and authorizing a value of amount for availing the hospitalization
benefits; electronically storing the value of amount to the access card for spending at the terminal;
inserting the access card into the point of service transaction terminal after availing the hospitalization
benefits for enabling the card reader to read the stored nature of amount, deduct the portion of value of
amount spent on providing hospitalization benefits and electronically storing the unspent value of
amount; and electronically re-transmitting the unspent value to the third party administrator or Insured
in a predetermined time.
In an embodiment of the present disclosure the access card information is entered manually or by
inserting the card at the point of service transaction terminal.
The Non-limiting examples of the hospitalization data includes height, weight and blood group of
patient, line of treatment, date of admission, date of discharge, medical history, and estimated expenses
including room rent charges, OT charges, anesthetic charge, pharmacy and consumables.
The height and weight of the patient is entered at the time of admission to calculate the BMI (Body
Mass Index) to know the health of the patient, whether patient is healthy, overweight or underweight.
This helps the Third Party Administrator (TPA)/ Insurer to evaluate the medication being used for
treatment. Further, the blood group of the patient is also entered in order to identify the insurer. Also, it
helps in preventing fraud and abuse in health care services.
In an embodiment of the present disclosure the adjudicating element compute the said
hospitalization data by predefined logics.
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In an embodiment of the present disclosure the predefined logics are based on determination
regarding policy status active or inactive, patient covered or not, line of treatment covered or not, preexisting
disease, exemption, availability of sum assured and other eligibility norms defined in insurance
policy.
In an embodiment of the present disclosure the mapping of Line of treatment with ICD codes. The
International Classification of Diseases (ICD) is the standard diagnostic code for treatment availed and
same is entered in the point of service transaction terminal while discharge request is submitted. This
helps in preventing fraud and also helps to evaluate if the medical procedures given are in line with the
treatment.
In an embodiment of the present disclosure the value of amount is linked with a merchant ID of
the point of service transaction terminal.
An embodiment of the present disclosure provides a method for cashless transaction for availing
hospitalization benefits comprising: entering access card information into a point of service transaction
terminal for initializing cashless transaction; entering and storing hospitalization data on the storage
medium of the terminal; transmitting the hospitalization data and the access card data to an
adjudicating element provided by a third party administrator or Insurer; computing the hospitalization
data and the access card data for determining eligibility and authorizing a value of amount for availing
the hospitalization benefits; electronically storing the value of amount to the access card for spending at
the terminal; inserting the access card into the point of service transaction terminal after availing the
hospitalization benefits for enabling the card reader to read the stored nature of amount, transmitting an
information regarding uploading the value of amount in the access card to hospital and card holder,
deduct the portion of value of amount spent on providing hospitalization benefits and electronically
storing the unspent value of amount; and electronically re-transmitting the unspent value to the third
party administrator or Insurer in a predetermined time.
In an embodiment of the present disclosure the information regarding uploading of amount to both
hospital/service provider and card holder (customer/patient) via SMS, Email and Telephonic call.
In an embodiment of the present disclosure the unspent value will be re-transmitted within 24
hours from the time it is electronically stored on the access card.
The point of service transaction terminal in accordance with the method of the present disclosure
accepts an access card, such as general master card, visa and Amex transaction cards for availing
hospitalization benefits. The point of service transaction terminal is used for financial transactions
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wherein the Hospital TPA Desk executive is entering the access card information manually or by
inserting the card at the point of service transaction terminal. The Hospital TPA Desk executive enters
the hospitalization data at the point of service transaction terminal including height, weight and blood
group of patient, line of treatment, date of admission, date of discharge, medical history, and estimated
expenses including room rent charges, OT charges, anesthetic charge, pharmacy and consumables. The
hospitalization data along with the card number flows to an adjudicating element/ claim processing
Application via a switch.
The adjudication of the hospitalization data entered by a Hospital TPA Desk executive by an
adjudicating element is substantially done in real time to determine the pre-authorized value of amount
for availing the hospitalization benefits. The adjudicating element approves or decline cashless request
based on the predefined logics designed at the server level. The adjudicating element performs
eligibility check based on the predefined logics. The predefined logics are based on determination
regarding policy status active or inactive, patient covered or not, line of treatment covered or not, preexisting
disease, exemption, availability of sum assured and other eligibility norms defined in insurance
policy. Based on the eligibility the claim is adjudicated and cashless approval information is shared
with value of authorized amount. In case, the cashless authorization is declined, the same is conveyed
to the service provider with decline reason.
In an embodiment of the present disclosure, at the time of cashless hospitalization approval, only
30 % of the estimated amount entered is approved and approval slip is generated. At this stage no
amount is transferred to Hospitals or service provider.
An embodiment of the present disclosure provides a method which is not limited to package
treatment but open to all line of treatment.
A preferred embodiment of the invention will now be described in detail with reference to Figure
1. Those skilled in the art will appreciate that the description given herein with respect to the figure is
for exemplary purposes only and is not intended in any way to limit the scope of the invention. All
questions regarding the scope of the invention may be resolved by referring to the appended claims.
Figure. 1 illustrates a flow diagram for cashless authorization for availing hospitalization benefits
at the time of admission of a patient. As illustrated in Figure. 1, a customer (patient) hand overs the
access card such as general master card, visa and Amex transaction cards for availing hospitalization
benefits to a Hospital TPA Desk executive at the time of admission. The point of service transaction j
terminal is used for financial transactions wherein the Hospital TPA Desk executive is entering the j
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access card information manually or by inserting the card at the point of service transaction terminal.
The Hospital TPA Desk executive enters the hospitalization data at the point of service transaction
terminal including height, weight and blood group of patient, line of treatment, date of admission, date
of discharge, medical history, and estimated expenses including room rent charges, OT charges,
anesthetic charge, pharmacy and consumables. The hospitalization data along with the card number
flows to an adjudicating element/ claim processing Application via a switch. The hospitalization data
entered by a Hospital TPA Desk executive is adjudicated by an adjudicating element substantially in
real time to determine the pre-authorized value of amount for availing the hospitalization benefits. The
adjudicating element approves or decline cashless request based on the predefined logics designed at
the server level. The adjudicating element performs eligibility check based on the predefined logics.
The predefined logics are based on determination regarding policy status active or inactive, patient
covered or not, line of treatment covered or not, pre-existing disease, exemption, availability of sum
assured and other eligibility norms defined in insurance policy. Based on the eligibility the claim is
adjudicated and cashless approval information is shared witii value of authorized amount. In case, die
cashless authorization is declined, the same is conveyed to the service provider with decline reason.
Figure. 2 illustrates a flow diagram for payment to a service provider at the time of discharge of a
patient. As illustrated in Figure 2. the value of authorized amount is transferred/uploaded to an access i
card. The audiorized amount is restricted to point of service transaction terminal from where cashless '
authorization was initiated and approved. Further, the authorized amount is linked with a merchant ID [
of the point of service transaction terminal. The communication regarding uploading of amount is sent *
to bodi hospital/service provider and card holder (customer/patient) via SMS, Email and Telephonic
call. At the time of discharge, me card holder swipes the card at the designated point of service
transaction terminal for payment. Further, if the card holder does not swipes the card at the designated
point of service transaction terminal for payment then all non utilized payment gets rolled back within
24 hours.
Although the subject matter has been described in considerable detail with reference to certain
preferred embodiments thereof, other embodiments are possible. As such, the spirit and scope of the
disclosure should not be limited to the description of the preferred embodiment contained therein.
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WE CLAIM:
1. A method for cashless transaction for availing hospitalization benefits comprising:
entering access card information into a point of service transaction terminal for initializing
cashless transaction;
entering and storing hospitalization data on the storage medium of the terminal;
transmitting the hospitalization data and the access card data to an adjudicating element
provided by a third party administrator or Insurer;
computing the hospitalization data and the access card data for determining eligibility and
authorizing a value of amount for availing the hospitalization benefits;
electronically storing the value of amount to the access card for spending at the terminal;
inserting the access card into the point of service transaction terminal after availing the
hospitalization benefits for enabling the card reader to read the stored nature of amount, deduct
the portion of value of amount spent on providing hospitalization benefits and electronically
storing the unspent value of amount; and
electronically re-transmitting the unspent value to the third party administrator or Insurer in a
predetermined time.
2. The process as claimed in claim 1, wherein the access card information is entered manually or by
inserting the card at the point of service transaction terminal.
3. The process as claimed in claim 1, wherein the hospitalization data includes height, weight and
blood group of patient, line of treatment, date of admission, date of discharge, medical history, and
estimated expenses.
4. The process as claimed in claim 3, wherein the estimated expenses includes room rent charges, OT
charges, anesthetic charge, pharmacy and consumables.
5. The process as claimed in claim 1, wherein the adjudicating element compute the said
hospitalization data by predefined logics.
6. The process as claimed in claim 5, wherein the predefined logics are based on determination
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regarding policy status active or inactive, patient covered or not, line of treatment covered or not,
I pre-existing disease, exemption, availability of sum assured and other eligibility norms defined in
insurance policy.
7. The process as claimed in claim 6, wherein the line of treatment is mapped with ICD code.
8. The process as claimed in claim 1, wherein the value of amount is linked with a merchant ID of
the point of service transaction terminal.
9. The process as claimed in claim 1, further comprising transmitting an information regarding
uploading the value of amount in the access card to hospital and card holder.
10. The process as claimed in claim 9, wherein the information is transmitted to the hospital and the
card holder via SMS, Email and Telephonic call.
11. The process as claimed in claim 1, wherein the unspent value will be re-transmitted within 24
hours from the time it is electronically stored on the access card.