Mumbai: Star Health Insurance, the largest health insurance company in the country, expects most cashless hospitalisation claims to be settled straight through using artificial intelligence within two years. Currently, a fifth of the claims are settled using AI helping the company meet the timelines for pre-admission and post-discharge hospitalisation.
A directive from the regulator requires completion of pre-admission authorisation within one hour and post-discharge authorisation within three hours, requiring efficiencies.
“Cashless claims account for about 85% of claim value and roughly 70% by number. Around 20% of claims are processed straight through using AI without human intervention, and we aim to increase this to over 50% in two years. Human intervention will primarily be for exceptions, high-value claims, or suspected fraud,” said Anand Roy, CEO, Star Health.
‘Cashless claims’ are those where hospitals agree to a schedule of rates with the insurer, who then approves treatment once a request is received from the hospital. In the absence of regulations on hospital pricing, the General Insurance Council is entering into agreements on a schedule of rates with individual hospitals.
“The Council is working towards common empanelment of hospitals, with a target of onboarding at least 10,000 facilities. The focus is on transparent billing, standardised treatment protocols, and digital integration through initiatives such as NHCX and ABHA.
