GIPSA, PPN and Empanelment in Health Insurance - Explained
GIPSA, PPN in GIPSA, Points to remember before opting GIPSA services, hospitals, empanelment
February 20, 2023
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Over the years we have seen health insurance costs skyrocketing irrespective of metro and non-metro cities. It was common that private medical hospitals were charging higher for patients having health insurance coverage compared to those who don’t. Neither insurance policyholders nor the insurers loved this.
In order to prevent this, health insurance providers tie up with different hospitals across the country and include them in their “Network Hospital”.
This enabled two things -
☝️ Standardized pricing
✌️ Easy payments for policyholders.
When you buy a group health insurance from an insurer don’t forget to check their network hospital list. This helps your employees to have a better medical experience.
Every insurance carrier ties up with a list of hospitals across the country. These hospitals are called the network hospitals of the particular insurer. You can generally find the list of network hospitals of a particular insurer on their website.
💡 The fundamental advantage of network hospitals is the cashless claim facilities for the policyholders.
For instance, if you fall sick and get admitted to any of the listed hospitals (network hospitals), then you do not have to worry about any cash costs. Here your insurance carrier takes complete responsibility for bearing up the cost and directly settles with the hospital.
Read: Top general health insurance companies in India 2022
The hospitals that are not listed under the contract while issuing insurance from an insurance carrier are referred to non-network hospitals.
💡 Mind you, non-network hospitals do not provide health insurance policyholders with the benefit of cashless claim facilities.
For instance, if there is an emergency and you have to go to a non-network hospital, you will be responsible for paying the medical bills all by yourself. You can only claim the costs after you meet the necessary documentation formalities for reimbursement.
Read: GIPSA, PPN and empanelment
Ms. Seema catches viral flu and gets admitted to one of the insurer’s network hospitals which are in her proximity. Seema’s sister comes to the hospital to help her out. All she has to do is inform the TPA, share policy details and submit a pre-authorization form. This is generally available at the hospital desk. Now, the TPA verifies and informs the hospital that Seema is pre-authorized and pays her medical bills. Here the hospital claims the bill from their insurance company. Seema does not have to submit any bills to the insurance company. Moreover, there is no waiting period to get a benefit.
However, as per the terms and conditions, there might be a case which she still needs to claim reimbursement from her insurance company. This is a rare incident to happen in a network hospital. In such cases, Seema pays the hospital and then files for reimbursement. If certain expenses are not covered under her policy then she needs to pay for only those uncovered expenses which are clearly communicated at the time of buying the policy. The remaining will get reimbursed.
Read: Role of TPA in health insurance
Mr. Tiwar had a sore throat for a few days and decided to go see a doctor. He had a health insurance plan but got admitted to a non-network hospital. Here it makes no difference if Mr. Tiwari had a cashless benefit or not because he decided to get admitted to a non-network hospital. Because you can't get a cashless facility in a non-network hospital. After his treatment, Mr. Tiwari had to bear entire expenses on his own and later claim reimbursement. Chances are that the claims can be fully or partially reimbursed by the insurance company after carefully reviewing the terms and conditions of the policy.
One takeaway from these scenarios is that it is better to get admitted to a network hospital unless there is an unavoidable emergency.
After explaining the differences, it is crystal clear that you should always visit network hospitals. Only at the time of unavoidable health emergencies, it is advisable to visit the hospital nearest your proximity. In such unavoidable circumstances, it is unwise to start searching for a network hospital and waste time traveling. Even a second can make a huge difference in the time of a health emergency.
To put it in a simple way, the claim process is always faster, smoother and hassle-free at network hospitals. All your paperwork and payment is taken care of and you really do not have to go through those tedious processes. If you are sick and have to get admitted to the hospital, you can simply walk into your network hospital and get the pre-authorization submitted. They will do the required due diligence before sending it to the Third-Party Administrator (TPA). The Third-Party Administrator (TPA) will process and approve your claim after going through all the terms and conditions of your health insurance policy. Once it is approved, the Third-Party Administrator sends you an authorization letter stating the treatment amount is now approved. Mind you, this entire process is completely cashless with no waiting time.
In the case of a non-network hospital, it requires policyholders to pay the entire amount upfront, submit all the documents and bills then claim for the reimbursement. Here, the waiting period is 10-15 working days for verification. People face a lot of issues with their medical expenses not getting approved which means it has higher chances of not getting the approval. There is so much scrutiny around hospitalization claims at non-network hospitals not to forget all the hassle one goes through.
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