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Cashless hospitalization process


Posted Date: 23-Mar-2011  Last Updated:   Category: Insurance    
Author: Member Level: Gold    Points: 45


This resource is to educate the people on various aspects related to the benefits under the insurance policy. It focus on the various queries related to cashless hospitalization process.



Cashless service ensures that you and your covered family members get treatment at the hospital empanelled in the TPA Network Hospitalwithout having to pay any money. This is however, subject to approval from the TPA based on the benefits covered under the policy.

Although most of us understand the term broadly, read on to know more about some of the unanticipated situations you may face during the cashless hospitalisation process.

Question 1: Recently when my colleague was admitted, the hospital had sent an initial estimated bill of Rs.35,000 to the TPA; however, the TPA only approved Rs.12,000. Does the TPA always approve lesser amount than the total estimated amount?

Answer 1: Please note that in most cases pre-approved amount will be lesser than the final amount and this fact is known to Hospitals. The initial approval is sent so that the Hospital can continue the treatment of the patient. At the time of discharge, the final bill amount is faxed to the TPA and the TPA approves the rest of the amount based on the policy terms and condition of the policy.


Question 2: Some hospitals tend to ask for certain advance payment when patient get admitted for cashless. Why should a patient pay when cashless facility is available?

Answer 2: In case of emergency hospitalisation, cashless process is initiated only once the patient is admitted. As it may take few hours to process the cashless, hospitals ask for advance so that they can initiate the treatment without waiting for cashless approval. Once the approval is received from TPA, you are requested to ask the hospital to return the deposit made by you.


Question 3: Is it possible to have cashless approval for Pre and Post Hospitalization?

Answer 3: Cashless Facility will not be given for Pre & Post Hospitalization expenses. Reimbursement of these expenses is possible on production of complete and detailed bills and documents relating to the same.


Question 4: There was a cashless treatment for my spouse last month. The service tax was charged in the final bill. Is Service Tax applicable on Cashless Claims?

Answer 4: The Central Government has introduced service tax on cashless services in Hospital and Nursing Homes for treatment. Hospitals are required to add Service Tax @10.3% to the patient's bill, in case the patient avails cashless treatment. The charged service tax will be borne by the Insurance Company as per the agreed terms and conditions of the policy.


Question 5: If there is a co-pay of 20% in the policy, is the service tax applicable on the amount that has been deducted by the TPA on account of co-pay?

Answer 5: No. The service tax will be applicable only on the amount approved by the TPA under the cashless facility. No service tax should be levied on the amount deducted on account of co-payment or any other deductions made under the policy.


Question 6: Will I get my claim papers back if I need it for my future reference?

Answer 6: No, you will not get the original claim papers back even after settlement of the claim as the same will be retained by the hospital for further settlement with the TPA. You are requested to arrange for a photocopy of the same for your future reference, before submitting the papers to the hospital. However, films (X-ray, CT Scan, MRI, etc.) can be obtained from the TPA once the cashless is settled by the TPA as the same cannot be photocopied for future reference. Do remember to put the request for the same to your Vantage representative or TPA in advance.


Question 7: Can I leave once the doctor has given a go ahead to me for discharge? Do I need to contact the TPA desk again for formalities?

Answer 7: On doctor's approval for discharge, the billing desk at the hospital first prepares the final bill and discharge summary which is faxed to the TPA for further approval. The TPA then based on the documents received, approves the rest of the bill and faxes back to the hospital TPA desk.

You are supposed to clear the unpaid amount (for example, the deductions based on the policy terms, the cost of nonpayable items etc.) to the hospital. The entire process usually takes around couple of hours and please do not forget to follow up with the TPA desk in the hospital on the status once the final bill is faxed to the TPA.


Question 8: If I go to higher category of room than what is allowed in the policy, do I just need to pay the differential room rent amount?

Answer 8: Along with the differential claim amount, you will also need to pay the associated incremental charges that increase with the increase in room category. For example, for hospitals certain charges like surgeon charges, doctor visits etc. differs according to room categories and the same needs to be borne by the insured.


Question 9: Do I need to show anything to the hospital while going for a cashless treatment?

Answer 9: You must carry the patient's cashless card (copy of the e card will also work fine) provided by the TPA along with a valid photo id of the patient.


Question 10: The TPA had sent the initial pre-authorization amount when my colleague's father was admitted. However, when the final bill was sent for approval, the TPA denied the cashless. On what grounds can cashless be denied after providing initial pre-authorization?

Answer 10: Cashless in such cases is denied by the TPA usually on the following grounds:
If the patient is hospitalized only for investigation/ observation or monitoring purpose and ultimately no active line of treatment takes place.

The proposed line of treatment provided in the pre-authorization form by the doctor deviates from the actual treatment process and the TPA doctor does not find it relevant enough.
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Responses to "Cashless hospitalization process"
Author: Hareesh Vemuri    01 May 2011Member Level: Silver   Points : 1
Dear Nilesh,

The Faq's are quite informative.However a doubt if a person have two policies ,one is mediclaim second one is Accident policy.If a person met with an accident and thru mediclaim he availed cashless hospitalization.After his discharge he is not left with any medical reports, how do he apply for his accident policy.

As accident policy claim requires same documents like discharge summary ,medical reports etc.

Please clarify my doubts.

Regards,
Hareesh



Author: Nilespan    02 May 2011Member Level: Gold   Points : 1
Hi Hareesh,

Please note that when you take claim under health insurance policy and the claim amount is full then you can not take the same benefit from your other policy. This facility is only provided when your cost of hospitalization in more than the covered amount and then you can take claim benefit of remaining amount from the second policy.

To avail this facility you need to take the letter from the first insurance company that you have taken benefit from them and you would like to take the balance amount reimbursed from your second policy.



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