Delays in insurance claim approval and until payment realization are really painful for hospitals as well as patients. They tied up their expertise with NBFCs for hassle-free claim assistance and approval.

We Assist wanted to manage two possibilities

1. Patients having valid insurance cards. Still, the hospital may only have a Cashless facility, then some NBFCs need to finance the patient to continue the treatment.
2. The hospital is a Cashless facility and there will be a delay in settling the claims from insurance companies until then some NBFCs need to finance the bills until insurance claim settlements.

In Both cases, they need Insurance claim specialists to coordinate with NBFCs to assess the documents and procedures from the hospital to audit and help streamline the whole insurance claim process.

We Assist wanted to use ERPNext for the following process:

The insurance claim process starts from CAR (Claim Assistance request) from the Hospital desk along with the Insurance documents, and patient PAN card details. These details are sent to the back office team. They verify the insurance documents to verify and approve the validity. PAN details and Adhar is used to verify the creditworthiness of the patient for the loan approval for the treatment from NBFC. After this lot of documentation is created and passed to various documents to the back-end team for approvals and verifications, some of the key document flows are CAR from the hospital desk to the back office.

• Patient contract approvals: Approvals are done by in-house/third-party medical specialists after examination procedures and verification
• Discharge verification as per insurance standards.
• Bill transfers from NBFC account to hospitals and transfer of amount from Insurance companies to patients and back to the NBFC’s account for loan closure.
• All these document verification procedures and approvals need to happen within 30 mins to 2 hours as these timelines are critical for patient admissions, treatments, and discharges.

To do this, Wahni, a trusted and authorized Frappe Partner built the following

• Project Stats DocTypes: 185 doctypes to capture different information across the business.
• Workflows: 25 + to review the actions at every stage to ensure efficient and complete claim submission to the Insurance company & TPA
• Checks: 3 Critical checks that evaluate the Insured/Patient across Finance, Insurance, and medical admissibility for required approvals and consider the case for admission/discharge.
• Unified Cash Ledger (5+ Ledgers) to track and help drive closure of all transactions from Lender, Hospital, Insured / Patient, and any other participating partner.