Insurers move to PPN, will this help facilitate cashless treatments?  

July 21, 2010

Insurer-funded healthcare cost is more than individual funded cost in India. Ergo, a Preferred Provider Network might help to reverse this trend

According to M Ramadoss, chairman & managing director of The New India Assurance Co Ltd, “Insurance companies have been witnessing inflated, fraudulent, and unwarranted hospitalisation claims when the patient had declared that he/she has insurance cover and wishes to go for cashless treatment. Due to this, insurer-funded healthcare cost is more than individual funded cost. The reverse is true in developed countries.”

Over the past few weeks, the healthcare industry has been in turmoil after cashless facility was revoked all of a sudden from leading hospitals. PPN (Preferred Provider Network) is a network of providers who agree to negotiated rates on specified procedures. New India Assurance has restricted cashless facility to hospitals in PPN. The concept of PPN is widely present in the US to ensure that insured funded healthcare cost is less than individual funded cost.

PPN will include hospitals who agree on standard rates for procedures/treatments. According to Mr Ramadoss, “We have 380 hospitals who have agreed to be part of our PPN. Ideally, we want as many hospitals on board as possible. The rates could vary from hospital to hospital based on location, facilities, equipments, etc. It is not one-size-fits-all. If there is an industry standard for standard rates, we will welcome it. Due to the absence of it, I have to step in but not to rob hospitals of their profits. We are trying to benchmark average costs of the previous two-three years and using recommendations of doctors on panels to come up with frozen standard rates for procedure and treatments.”

The disadvantage for New India Assurance policyholders is the need to raise money if they wish to go to hospitals outside of the PPN. According to Mr Ramadoss, “Out of 100 policies, 8% make claims of which 35% is cashless. It means only 2.8% of claims we get are cashless. It is not (a) great disservice. Unlike in the US, the supply constraint is present in India for quality healthcare. We are trying to bring as many hospitals on board (the) PPN. If the patient is unable to go to a PPN hospital, the reimbursement will still happen after the claim is submitted.”
 
A ‘limited hospital list’ (around 450 all over India) would offer better administrative control. TPAs can drive more business to lesser number of hospitals and hence, can demand volume discounts. With better administrative control, all bad claims (fraudulent, inflated and unwarranted) can be reduced to a greater extent.

The success of PPN really depends on hospitals agreeing to be part of the network. While the Association of Medical Consultants (AMC) is already thinking of completely boycotting the programme, several hospitals on PPN may also opt out soon. The hospitals on the PPN have been given a fixed tariff rate card by government-owned insurance companies for more than 40 different surgeries. The rates, say industry insiders, are 50% less that what they charged earlier at bigger hospitals. In smaller hospitals and nursing homes the rates have been slashed up to 30%, upsetting healthcare providers. It is a trade-off between volumes of business versus standard rates for a hospital. There will be resistance to anything new and so the same is expected for PPN.

There are definitely winds of change blowing in the healthcare industry, which is bleeding under losses. New India Assurance itself is running losses of 20%—excluding administrative costs — for health insurance. The losses are over 40% when administrative and other costs are included. The loss scenario is present for the other three public sector insurers too. The initiative taken up by insurers has shaken up the hospital industry and made consumers anxious. We have reasons to believe that this is a start of some much-needed changes in the health insurance industry even though it may cause inconvenience to consumers in the short term. Lack of supply of quality healthcare in India is also one of the reasons which make it even more important for good hospitals to come on board PPN to make it successful.

— Raj Pradhan