Monitoring of health insurance claims?? In India, multiple and complex factors influence pattern of medical practice.

There is wide variation, even between large hospitals in Cat A/ B/ C cities. These variations are largely due to uncertainty over clinical diagnosis, investigations and/ or line of treatment adopted. This uncertainly can be attributed to difference in training (read experience), non-availability of certain modalities (both investigative and therapeutic), fear of litigation or simply agreeing to wishes of patients and/ or their families. Monitoring of health insurance claims?? Following are some of the common factors attributable to variations of decision making in medicine that adversely affect the health insurance industry. Medicine is as much a science as an art, there is great variability in medical decisions since presenting features of medical conditions are not uniform and different doctors have differing capabilities to interpret clinical signs and symptoms. With a wide range of tests available, for further work-up to confirm or rule out a clinical suspicion, their selection is based on a mix of (non)availability, individual judgement as well as personal preference. Treatment is always individualized and indications of treatment to be given and choice between an aggressive versus a conservative approach is not very well defined. Although international guidelines exist for Evidence Based Medicine in most cases; no doctor can be faulted for not adhering to them, at least not yet in India. Most doctors would rather err towards acts of commission (ordering unnecessary tests/ hospitalization) rather than acts of omission (missing out a necessary test/ hospitalization) again to chagrin of insurer.

With above said, medical decisions can and are influenced by financial considerations and lead to over servicing of clients (aka patients). Although, in a small percentage of cases over servicing may genuinely be due to a desire to provide the best to the patient, still providing more care to the patient in question does not necessarily mean better care; it would be worth its while to curb such over servicing since precious healthcare resources are wasted. Need of the hour is to monitor physician behaviour (read practice styles) and steer them towards achieving best health outcomes with best value for monies spent (especially of insurers) as it is possible to save resources without lessening quality of healthcare. In medicine, with best of scanners and analyzers, the man behind the machine is still Numero Uno. Similarly despite cutting edge technology, sophisticated analytical tools and comprehensive information system one needs medicos with

deep insights into medical practice patterns to decide logical / rational use of precious resources. What is required is to bring in a level of transparency hitherto not present in the process of healthcare delivery, especially the insured population, and find answers to questions concerning rational resource utilization, rational cost and highest quality of care. Dr C H Asrani
Chief Executive X-CLAIM Expertise in Insurance claims www.x-claim.in drchasrani@sclaim.in