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The Provider Standards group, pursuing its objective of suggesting mechanisms to achieve standards and transparency in treatment and billing, suggested that the industry could adopt standard definitions to enable effective and unambiguous interaction amongst all stakeholders. Mechanisms such as certification, regulation, quality assurance programs, peer review, consumer education, accreditation systems and norms for categorization and grading of hospitals for insurance purposes are to be considered. It was suggested that a common prior authorization form be developed for use by all TPAs, obviating the need for providers to stock the stationary of each TPA. Standardized treatment guidelines (STGs) can assist in bringing about quality of care and the group supported development of clinical guidelines. It was felt that some short-term and long-term measures to enhance the use of ICD 10 need to be outlined. There is a need to create training infrastructure, modules and core trainers in ICD-10, the group recommended.

The Payor Standards group pursued the objective of suggesting mechanisms to standardize the key processes and terminology which drive the policy wordings, underwriting and claims processes. The group recommended that to ensure that customers are not ‘underwritten at claims stage’, all health insurance business should be underwritten at policy inception in a manner that is consistent with the pricing strategy and the risk appetite of the insurance company. Each company would be required to specify an internal underwriting policy framework. This policy framework should articulate the overall risk philosophy of the company and should be approved by the Board of each insurance company. The underwriting policy

would be captured in an underwriting manual, which should be updated for each new product launch - and should be included as part of the normal file and use process. To support the rollout of a best underwriting framework, a robust underwriting training framework should be developed. Each insurer should adopt a best practice claims management framework to create transparency in claims processing. Information on ‘turn around times’ [TATs] should be made available to public and monitored by the IRDA. Each insurance company would be required to create a claims manual which would specify the claims philosophy of the company as well as the claims processing and management guidelines for each product. All commonly used health insurance terms must additionally be expressed in Common Business English as part of the policy kit sent to the customer. These are meant to be explanatory in nature only – they do not change the legal position of the insurance company. Insurers should have the freedom to re-price the risk at a portfolio level, at the time of renewal. Re-pricing should be permitted for a class of policies and not at an individual policy level. The group also recommended additional focus on integration and interaction between payors and providers. Transparency to the customer about portability of benefits via a “Portability Disclosure” could be included as part of the policy terms and conditions.

The Communication and Awareness group was set up with the objective of building a concerted effort towards consumer education and health insurance awareness. The group recommended that multiple awareness messages need to be designed based on the message recipient and the nature of the market. The key communication objectives should be to explain what health insurance is and how it works. The objective would be to explain the philosophy of risk pooling, to educate the consumer on how to choose the right product, to create a positive image of health insurance and its role in protecting against medical emergencies, to provide clarity on benefits of products/services and to explain the main terms and conditions and what health insurance covers or does not cover and to educate consumers about the process


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