Student Dissertation

Agency : Health Insurance System; Insurance Claim Process; Cashless Insurance; In-Patient

Objective : • To study the processes of In-patient Insurance claim and discharges in SDMH Hospital • To study Turnaround time of discharge process (of cashless patients) • To study Number of queries from TPA and assess the rejection rate of claims and their major causes.

Background : Insurance claim process for the cashless patient is very crucial and time consuming for the patients. The hospital faced heavy revenue loss and dissatisfaction among the discharge patient due to delay in Insurance claim process. This also resulted in delay in discharges and new admissions.

Methodology : • Study Period: 2 months ( 3 march to 3 May,2015) • Type of study: Observation and descriptive study • Location: SDMH, Jaipur • Sample Size: 110 cashless In-patients patients admitted during study period. • Sampling method: Simple Purposive sampling. o Department time and sample collection time is 9:00 am to 6:00 pm. Monday to Sunday. Data to be collected: Primary data: • Observation, Claim portal and Registers • Secondary data: Medical records, Hospital SOPs

Findings : Average time taken by the hospital and by the insurance /TPA has been calculated. With the help of this delay for discharges due to hospital procedure and their various department which is responsible for the major delay has been analyzed. Delay for the discharges from the various companies/TPA studied and it was observed that the time required for handling number of queries is one of the major reason for the delay by company/TPA. Reasons for the queries and reasons for the rejections has been studied. Results were analyzed with the help of Microsoft excel using tables and Pie charts. Bottlenecks: Unplanned discharges, Late morning round of doctors, Delay in preparing of Discharge summary, Information gaps in between staff and patient, Number of queries, Patient has no knowledge about the terms and condition of their policy.

Recommendations : • To take initiatives for planned discharges: • If we give the major focus on departments like Obstetrics & gynecology, GI surgery, Medicine, Urology, neonatology/pediatrics, Orthosurgery can solve nearly 80% problem of the delay in discharges. • If major focus given on companies from which maximum cases are coming. • Also by working on the various reasons for queries nearly 41% of the problems will be solved • All the Investigation reports which supports diagnosis should be send to the insurance company/TPA. • Common software (in HMIS) should be there to prepare discharge summary rather than different formats for different department • RMOs should update discharge summary on daily basis.The summary is to be checked and signed by the doctor/ consultant during his morning visit to the patient on the day of discharge. • Frequent training to the doctors, nurses and to GDAs should be given about the discharge process of the TPA patients in the hospital •patient or their relatives should go through all the terms and condition of their policy or should clear it from their agents in case of planned admissions. • Discharge lounge arrangement