The Need
Health Insurance - Cashless Claim

The Need

Insurance orgs are diversified and their operation involves  covering various needs of human life ,business and society. It is  data intensive, time critical and utmost risk sensitive. Now a days many complex home grown custom apps, integrated with 3rd party products and many feeds coming in from the field. In such a distributed environment, it is difficult to isolate performance issues.

Providing an exceptional online customer experience and litigation free is the top most priority. On one end, there will be consumers; on the other side, there will be agents, dealers, agencies/hospitals, banks and aggregators. When various operators are involved in Proposal Entry, Underwriting, Claims settlement, a small delay in the process chain will have a huge impact on business performances .

  • Is  your customer able to do a premium payment  from his desk, get accurate policy status details updated  in  few seconds?
  • Is  the insurance office able to manage 1000s of policy holders renewal  notices?
  • do regular advance claim intimations and settle monies in due time?
  • Is your customer support team getting calls about customer frustration in accessing the insurance app?
  • Do you get complaints on policy feeds being slow, from aggregators?
  • How fast is your day end and month end operations, when your agents are pumping in large volume of data?

When the business teams worry about the above questions, the IT Infrastructure team has its own set of questions to satisfy..

  • Are all servers and apps, available 24 by 7 to all users?
  • Are the apps performing fast for online and batch operations?
  • Are we using the hardware capacity in an optimized way?

Every piece of the insurance application must interact well and fast, to achieve these goals.
Resileo can monitor all components of  your insurance application and ensure a great experience in performance to the customers.

Health Insurance - Cashless Claim

Claims process in most of the Health Insurance firms follows either cashless or through reimbursement process. Claim can happen from registered hospitals or from non registered hospitals. Registered hospitals include hospitals that are approved by the Insurance Company for processing the intimations on behalf of the insurer. For all the non registered hospitals, insurer has to go through the reimbursement mode to complete the claim process.  Let us understand how it works in the health insurance sector.

General processes for the claim are as follows

  • Creation of intimation
  • Auto/Manual registration of the intimation
  • Get the documents as scanned copy
  • Authorize the claim – Approve, Reject, send for query
  • Process claim – on approved claim
  • Send for query on claim authorized for query
  • Send for second level Authorization on rejected claim
  • Check for any enhancement before payment process
  • Send for payment process

Cashless claim is performed within a timeline of 20 to 30 min from the time it is initiated and mostly all the process are automated. Cashless is only possible with the registered hospitals

Cashless Claim

Cashless claim process is initiated by Hospitals directly into the portal of the insurance Company and it is expected that more than 1000s of hospitals do this claim at any point of time with many  insurance companies. This means the performance of the servers and the connectivity supported to each of the hospitals play critical role to ensure the insurance claim process is efficient and effective.

The above process is very critical as the diagnosis is dependent on the approval of the intimation from insurance for the hospital to proceed. Any delay here, might lead to chaos and confusion leading to patient dissatisfaction. Most importantly the trust within the customer gets reinforced, only when the supporting online system responds faster.

As soon as the claim intimation gets generated it has to go through certain pre defined activities within the system like

  • Analyzing and validating previous claim details
  • If any of the below is not satisfactory, then referring to the internal team for next course of action.
  • Validating the nature of disease
  • Policy validity
  • Sending for approval on valid intimation

All the above must happen within short time (most of insurance Company claim this to happen within 20min from the time intimation is created in the system)

Once the intimation goes through first level of acceptance, then before the payment is being made to the insurer, following activities are done by the hospital or through the service agent of the insurance company, once the procedure is over on the patient and before getting discharged from hospital.

  • Initiate for enhancement, if any from hospital
  • Processing the enhancement process on valid enhancement request.
  • Getting the physical document like invoice, details of procedure done etc., through scanned copy and getting it validated manually in the system by respective in-charge, authorize and approve it in the system
  • Send approval to hospital on valid intimation.

Once the approval is sent, the Insurance Company takes that intimation for payment process as per agreed terms.

With the above process, it is very important the server is capable of doing multiple activities with various checks in place. System requires to be tested with 1000s of claim initiated from various hospitals to understand the real capability and try to understand hardware performance, code performance for the generated load. With the actual performance testing it is possible to arrive at the stress point, and analyze the code for further optimization.

If it is not tested, there is every  possibility that we might oversize the hardware without any valid reason. It is proven in various industries; by doing the performance testing, for the most used business transactions and optimizing the code based on the result, resulted in reduction of 50% or more of the estimated hardware cost.

With the load testing, it is also possible to arrive at the threshold values of certain critical performance counters. Continuous monitoring allows the ops team to take the right decision well before the hazardous situation happens.

‍Customer List

IIT Madras
HCL Technologies
Global Analytics
Enstar Group
Daimler Chrysler Research & Technology
TVS Logistics
Star Health
L&T Infotech

Dr. V. Krithika, M.S., Ph.D.
Honorary Guide
Expert - Healthcare Data Analytics
Passionate about the mathematical concepts behind ML/AI, Management
Sriraman Kalyanaraman
Senior Project Advisor, ICSR, IIT Madras
Principal Data Architect, Resileo Labs
Research on data analytics/Machine learning.
Development of data models for different industries
Planning for dashboard visualization and dashboard security
Development of APM open source tool - APPEDO
Pichumani Nagarajan
Founder & CEO, Resileo Labs

Data analytics, ML, AI
Kaushik Raghavan
Data Architect, Resileo Labs

Data analytics, ML, AI
Test automation
Internet scale performance testing and tuning
Currently doing PhD at IIIT-DM Kanchipuram on data analytics