How India’s Health Claims Exchange (HCX) Will Revolutionize Health Claims

Insurance Regulatory and Development Authority of India (IRDAI) and National Health Authority (NHA) are developing a National Health Claims Exchange (HCX) as a digital platform to settle health claims.

What is it and what does it hold for the healthcare space?

Current Landscape:

The current health insurance claims settlement process is manual, non-automated and human intensive with major hurdles in each step:

1. Patient experience is burdensome with low transparency on the status and long wait times
2. Regulators receiving delayed and incomplete data
3. Insurers get uncoded data which they have to digitize themselves, leading to manual errors and limited fraud analytics

HCX — Reimagining Health Claims Through An Exchange

Introduce a common digital format for claims across all players — private & govt.

Create HCX — A digital public infrastructure which processes & moves information across providers & players & settle health claims

Capabilities of HCX:

1. Coverage Eligibility: Check policy validity by provider including exclusions
2. Claim Status: Track status of any claim across players
3. Smart Contracts: Automated transfer of payments on claims approval through HCX platform
4. Provider Facility Info: Machine readable info on providers that be used by payers for empanelment/fraud check
5. Policy Details: Creation of policy markup language to describe key elements of policy
6. Digital Contract: Digital MoU moving to paperless contracts)

HCX Will Act As An Accelerant For The Ecosystem

Insured:

a. Discover linked health policies

b. Wallet management

c. Digital KYC prior to pre-auth

Insurers:

a. Fully digital data from providers

b. Lower costs by using automation for verification

Providers:

a. One interface to file claims — completely paperless

b. Track every claim from pre-auth to payment

c. Faster times for pre-auth/patient discharge

Industry / Policymakers:

a. Help move towards UHC using digital public good

b. Real time data on SLAs

HCX Will Revolutionize Cashless Health Insurance:

1. Improved patient’s claim related experience
2. 2. Better visibility & tracking of claims
3. Reduction in claims processing cost
4. Faster claims
5. Newer innovative products
6. Better data quality for stakeholders

HCX will be a breath of fresh air for the health insurance industry in India which is still under penetrated compared to global peers and would help build trust which is currently lacking!