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Report on Standardizing Preauthorization Requests for MedicalCare


  • Aparna
  • Agency : Indus Health Plus, Feedback, Analysis, Data Discrepency
  • Objective : Health Insurance is the assurance against the risk of insuring medical expenses among individuals. It is the insurance against loss by the disease, illness or body injury that was not caused due to personal choice. It does not cover the life style diseases. IRDA has formulated guidelines for the health Insurance sector on Feb, 22nd, 2013. The guidelines will standardize definitions of 46 clinical terms that are commonly used in health insurance policies in order to bring uniformity in adjudicating claims and the settlement processes. Further, Insurance Companies have developed clinical norms for medical claims. This study will enable proper adjudication during authorization process. Universal model for medical care covers in order - clinical assessment, stage of diagnosis and level of treatment, criteria for and plan during hospitalization, plan to assess prognosis and follow up care. The cases selected for the study are the Medical management cases as they have highest volume of cases that are claimed by insured members, high variation in care and costs, high dependence on precise entries to adjudicate against relevant insurance norms. The data of preauthorization requests of one month (March 2013) and respective claims data has been collected from the MIS department. The cases as per the symptoms are separated and the cases with highest number (4 types) are selected (fever, cough, pain, vomiting). Then 30 cases form each category (fever, pain, cough, vomiting) are selected as sample by using the stratified random sampling technique. The data of the 120 cases has been entered in a particular framework. The changes from preadmission through interim changes till discharge and findings against the universal model for clinical care are observed. The findings include the no. of cases with provisional diagnosis is more in the cases with cough symptom, the change in the diagnosis is more in the cases with cough symptom, the cases with cough symptom has high cases with increased length of stay and the amount for most of the cases in all the symptom categories is decreased when compared from preauthorization form to discharge summary. This indicates that there is a change in diagnosis at the time of admission and at the time of discharge and the amount the hospital estimates is high range always. In the above cases the doctors has to check the details and it take much more tme for processing. Hence these findings indicate for the standardization of the medical entries to avoid the confusion and to reduce the turnaround time 
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This study will enable proper adjudication during authorization process. Universal model for medical care covers in order - clinical assessment