Ahmedabad hospitals, Star Health at loggerheads

Dr Bharat Gadhavi, president, AHNA, says: “Over the past several months, our hospitals have encountered a series of problems that have adversely affected our ability to deliver timely and efficient healthcare services to your policyholders.”

Unhealthy Practice

•Star Health has tied up with 400 hospitals in Ahmedabad

•The insurer re-evaluating list of hospitals eligible for seamless claims

•Cashless claim settlement allows direct billing to insurance company

•Hospitals voiced concerns over abrupt suspension of hospital listings

Mumbai: Hospitals in Ahmedabad are at loggerheads with the private health insurer, Star Health and Allied Insurance Company, over exclusion of certain hospitals by the insurer for their alleged fraudulent claims and unjustified suspension of cashless claims. Star Health and Allied Insurance Company is the lone listed health insurer in the country. Now, Star Health and hospitals in Ahmedabad are trading charges over alleged fraudulent claims and unjustified suspension of cashless claims.

The insurer has decided to re-evaluate the list of hospitals eligible for seamless claims after serving notices to over 100 hospitals for alleged violations of contract and fraudulent claims.

Talking to Bizz Buzz, Dr Viren Shah, Vice president, Ahmedabad Hospitals and Nursing Homes Association (AHNA), says: “Over the past several months, our hospitals have encountered a series of problems that have adversely affected our ability to deliver timely and efficient healthcare services to your policyholders.” In fact, AHNA has threatened to discontinue cashless with the company. The insurer has tied up with 400 hospitals in Ahmedabad and has reportedly excluded a good number of the hospitals there on the allegation of fraudulent practices. It allegedly found that many of these hospitals are violating tariff rules and some engaging in frauds and has sent notice to them to discontinue cashless claim settlement, which allows direct billing to the insurance company by the hospital.

The hospital association has said that if the issues are not resolved by October 14, all hospitals may suspend cashless facilities to Star Health policyholders from October 15 to November 14 as a protest measure. Should these problems persist beyond this period, we will have no choice but to take more severe measures, including indefinite suspension of cashless services and reimbursement services, which will inevitably impact the policyholders you serve, it goes on.

The hospital association’s letter, widely circulated on social media platforms, has highlighted several challenges faced by member hospitals while dealing with cashless and reimbursement services for Star Health Insurance claims. The hospitals have expressed concerns over the abrupt suspension of hospital listings, claims being denied post initial authorisation, inadequate reimbursement rates, and prolonged delays in claim processing, putting considerable financial strain on healthcare facilities. This prompted some policyholders, too, to share their own experiences.

The genesis of the entire episode, which has spread like wildfire on the social media, began when an unidentified person tweeted about the difficulty, they faced in getting Star Health Insurance claim for treatment after an acute stroke. The claim was initially denied. Later, it was partially approved after putting in a lot of effort, including posting about the issue on X (formerly Twitter), the person said. The Ahmedabad Hospitals & Nursing Homes Association (AHNA) wrote to Star Health through an email communication on September 5, seeking a meeting to discuss issues related to member hospitals. As a result, the insurer held discussions with them on September 7. Health insurance is a highly regulated sector with IRDAI putting in place well defined regulations on all aspects of the business, including the engagement of insurers with the providers. These regulations are monitored closely by the authority to ensure that the industry abides by them. Star Health, being the largest retail health insurer has been abiding closely with these guidelines over the years.

“At Star Health, we are committed to provide the best health cover for our customers. This necessitates a constant engagement with our network hospitals to ensure reasonable rates of treatment so that our policyholders do not unnecessarily exhaust their sum insured. Insurance is a common pool of funds by the people. As the custodian of this common fund, it is our responsibility to ensure that the fund is available to all who genuinely require it and pay-outs for unnecessary claims or fraudulent claims are minimized,” the insurer said in a statement. Star Health settles all legitimate claims. We have a dedicated in-house claim settlement team, comprised of experienced doctors. Rejection of claims mainly happens when policy conditions are not met, it said.

As per a spokesperson of the insurer, “We do not reject claims because the hospital charges are high. However, there may be a few claims that require in-depth investigations due to an alert on suspected fraud, either by hospitals, claimants, intermediaries or third-party aggregators. With our experience in the medical field, we have developed a very robust rule engine for claims. Multiple checks have been put in place to identify irregularities. Our tech-enabled fraud detection process flags suspected fraudulent claims. These cases are thoroughly investigated, and all legitimate claims are paid, it added.” As a responsible insurer we will continue to work in the best interest of our customers to ensure that they receive the best care and treatment at reasonable costs. We remain committed to ensuing our customers have a hassle-free experience in their time of need, it further said.