National Health Claim Exchange

National Health Claim Exchange

Context: India is launching a digital platform called National Health Claim Exchange (NHCX) to improve healthcare access and reduce out-of-pocket expenses for patients.

• NHCX will integrate insurance companies, healthcare providers, and insurance scheme administrators.
• The NHCX will serve as a central hub for health claims data, promoting seamless interoperability among stakeholders. This integration aims to enhance efficiency and transparency in claims processing.
• NHCX aligns with IRDAI’s vision of “Insurance for All by 2047.”
• As a centralized platform for all health claims, NHCX will significantly reduce the administrative burden on hospitals, which currently manage multiple portals for different insurers.
• Recently, IRDAI has mandated a three-hour timeline for processing cashless claims, starting from the receipt of discharge authorisation from the hospital.

Digital Health Incentive Scheme (DHIS)

• DHIS, initiated by the National Health Authority (NHA), aims to encourage the adoption of digital health transactions and the digitisation of patient health records across the country.
• Under the DHIS, hospitals receive financial incentives for processing insurance claims through NHCX.
• ₹500 per claim or 10% of the claim amount, whichever is lower.
• The incentives are given directly to the hospitals.

National Health Authority

• National Health Authority implements the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, the flagship public health insurance scheme. It also designs and builds the technological infrastructure for the National Digital Health Mission, which aims to create a digital health ecosystem.

Challenges

• Strained relationships between hospitals and insurance companies.
• The IT system and training staff are outdated.
• Discharge delays and miscommunications.
• Data Security.

Facts

• Health insurance contributes to 29% of India’s general insurance premium income.
• Hospitalization rates are highest among those with private insurance (54.4 per 100,000 persons) across India. In urban areas, government-funded schemes lead to the highest inpatient care (60.4 cases per 100,000), while in rural areas, private insurance dominates (73.5 cases per 100,000).
• Urban areas have higher inpatient rates than rural areas.
• In India, the share of Out-of-Pocket Expenditure (OOPE) in total health expenditure declined from 62.6% in 2014-15 to 47.1% in 2019-20.