The changing OPD scenario in India
Health insurance coverage for outpatient department (OPD) treatments typically includes medical costs for patients who do not require hospitalisation, such as expenses on consultations, diagnostic tests, and prescription drugs.
Health insurance in India has typically been synonymous with In-patient plans which cover hospitalisation and associated expenses; however, OPD coverage has now emerged as a significant part of health insurance programs.
In the last three years, the percentage of customers opting for OPD covers has quadrupled from 5% to 20%. The importance of OPD coverage became particularly evident during the pandemic and remains a key factor driving the demand for comprehensive insurance.
OPD coverage is a valuable addition to health insurance, especially for individuals requiring regular medical care. It also promotes preventive health by covering consultations and health check-ups allowing early detection and treatment, thus preventing more serious complications that could lead to hospitalisation. Many employers are now including programs to encourage overall employee wellness through out-patient coverage.
In India, OPD coverage is crucial for making healthcare both accessible and affordable and that too at a large scale. It offers a convenient and cost-effective way for individuals to receive medical attention without the need for hospitalisation. OPD plans vary widely, from basic coverage for doctor consultations to more comprehensive options that include diagnostics, medications, dental procedures and therapy costs. Typically, OPD plans provide coverage ranging from INR 10,000 to INR 75,000.
Out of those opting for OPD services, a significant 50% actively utilise OPD services included in their plans, showcasing the practical relevance and value of such a coverage.
From a customer service perspective, handling OPD claims offers a unique opportunity to engage more frequently with members compared to IPD claims. Each interaction is a chance to more deeply serve and delight customers, and build stronger relationships through consistent, positive experiences.
Challenges of executing a smooth OPD plan
Cumbersome Claims Process – The claims process for OPD plans is often complex and inconvenient, requiring policyholders to complete forms and submit bills and other documents. This process is particularly burdensome given that OPD claims are usually for smaller amounts and are more frequent compared to inpatient claims.
Risk of Misuse – From a payer’s perspective, there is a persistent concern about misuse. In India, where individuals traditionally visit local doctors or pharmacies for OPD services, there have been instances of fraudulent activities such as submitting fake bills for reimbursement. A trusted network thus becomes key.
From an Indian population perspective, the high volume of claims make it even more of a challenge.
Building Outpatient Cashless Services
To address these challenges, a successful approach involves leveraging technology and forming strategic partnerships to enable cashless services. Developing a cashless outpatient network through integration with multiple trusted aggregators helps streamline the OPD claims process and reduce the risk of misuse. Aggregators are platforms that consolidate trusted outpatient service providers, to bring a wide range of services. This innovation provides users with seamless access to cashless OP services without the need for reimbursement claims.
A few observable benefits that came in with aggregator partners
- Member Convenience – With a cashless system in place, members can effortlessly access outpatient services without the hassle of submitting reimbursement claims for minor expenses.
- Cost benefit – Outpatient Aggregators provide added value by offering discounted pricing.
- Streamlined Processing – This integration enables seamless communication, efficient claim processing, reduced administrative burden and enhanced operational efficiency.
- Fraud Prevention – System driven process minimises instances of fraudulent claims, as each transaction is accurately tracked and verified through the system. Aggregators also ensure that the outpatient network is a trusted one delivering high-quality care that meets the expectations of both patients and payers.
Leveraging Technology
- Real-time data exchange – API-based integration ensures smooth and secure data transfer between the health benefit administrators’ platform and multiple Aggregators’ systems. This enables a standardised integration interface to enforce OPD plan rules, facilitating accurate and compliant cashless transactions in real-time.
- Single Sign On (SSO) – SSO enhances user convenience and security. With a single set of login credentials, clients can access aggregator services seamlessly.
- Data Security – Robust encryption protocols help safeguard confidentiality, integrity, and availability of data throughout the transaction lifecycle, providing a secure environment for processing cashless claims.
Currently, cashless OPD services cover only about 40% of the industry, indicating significant opportunity for growth. This growth is set to be driven through large scale adoption of machine learning, digitisation and generative AI.
This article is written from a Health Benefits Administrators Perspective.
By Shubhra Singh, Head – Customer Solutions of Medi Assist