National Health Claims Exchange by National Health Authority

The National Health Claim Exchange (NHCX) is a digital health claims platform jointly developed by the National Health Authority (NHA) and the Insurance Regulatory and Development Authority (IRDAI) in India. The NHCX portal is almost ready and as of 25 May 2024, it is expected to be launched within the next two to three months. It is part of the Ayushman Bharat Digital Mission (ABDM), which aims to improve healthcare services across India. 

Overview of the Current Claim Processing

In the current scenario, patients who visit a hospital for treatment provide their insurance policy details or a card issued by the Third Party Administrator (TPA) or Insurance company. If it's the Pradhan Mantri Jan Arogya Yojana (PMJAY), then the card is issued by the State Health Agency (SHA). The hospital then accesses the claim processing portals of respective payers and upload the required documents for pre-authorization or claim approval process. That is exclusively designed for a specific policy or scheme.

On receipt of the pre-authorization/claim form, State Health Agency/the Insurance Company/Third Party Administrator (TPA) will authenticate and digitize the form using their internal claims processing portal. The claims will then be adjudicated by the relevant team. In India, a significant portion of the adjudication process is presently manual, whereas in many developed markets, over 90% of claims are auto adjudicate.

Challenges of the Current Process

• The current process of exchanging claims lacks standardization across the ecosystem.
• With most data exchange occurring through PDF/manual methods.
• Additionally, there are no established health standards.
• Processes vary significantly among insurers, TPAs, and providers.

To address these challenges, NHA along with industry experts have made standard domain specification and NHCX protocol and published for feedback from industry participants such as insurance companies, TPAs, and state health agencies. This collaborative and transparent effort aims to create an open, widely agreed Health Claims data Exchange Specifications that can be adopted as a public good. Specifications for Cashless Claims are now available for public consultation, and NHA is open to discuss

The National Health Claims Exchange Specifications serve as a blueprint for each aspect of the envisioned claims network, allowing for technology and vendor neutrality, adaptability to changing needs over time, and the promotion of innovation and inclusion.

Key points about NHCX

Purpose and Functionality: 

• NHCX serves as a single-window interface connecting health insurance companies, hospitals, and policyholders. 
• Its primary goal is to streamline the health claim filing process by replacing cumbersome manual procedures with a standardized, digitized system. 
• The platform acts as a gateway for exchanging claims-related information among various stakeholders in the healthcare and health insurance ecosystem. 

Stakeholders Involved: 

• Health Insurance Companies: NHCX provides a common platform for health insurance companies to process and settle claims efficiently. 
• Hospitals and Service Providers: Hospitals can use NHCX to submit details of treatments, expenses, and other relevant information for claim verification. 
• Policyholders: Individuals seeking health insurance claims benefit from the simplified process enabled by NHCX. 

Benefits of NHCX: 

• Faster claim processing: NHCX acts as a single platform for insurers, hospitals, and other healthcare providers to securely share claim data. This eliminates the need for manual paperwork and facilitates faster claim approvals.
• Improved interoperability: The platform ensures seamless exchange of standardized health information across different healthcare systems. This reduces the chances of errors and delays due to data incompatibility.
• Enhanced transparency: NHCX promotes transparency in the claim settlement process. Policyholders can easily track the status of their claims and access relevant information.
• Benefits for all stakeholders: By streamlining the process, NHCX is expected to benefit all parties involved. Patients will experience quicker claim settlements, hospitals will receive faster reimbursements, and insurers can improve operational efficiency.

Current Challenges Addressed: 

In the existing process, patients provide their health plan details to hospitals, which then initiate the claims process. 

Hospitals access the insurer's platform to submit treatment details, including expenses and duration. 

The insurer verifies the claim based on diagnosis reports and approves it. 

However, managing multiple companies, patients, and portals makes this process bulky and time-consuming. 

NCHX is believed to be accessible across India from the launch date, and sources said it will initially provide a connection between stakeholders of already-linked 50 insurance companies and 250 hospitals, with more hospitals and insurers to join in the future.

Many major players such as Aditya Birla Health Insurance Company Limited, Star Health and Allied Insurance Co. Ltd, Bajaj Allianz Life Insurance, HDFC ERGO General Insurance, ICICI Lombard General Insurance Company Limited, New India Assurance, TATA AIG General Insurance Company Limited, and United India Insurance Co. Ltd., have already finished integration with NHCX.

After IRDA mandated that all insurance policies should be issued in electronic form from April 1, leading to insurance plans of one individual consolidated in his e-Insurance Account (eIA), NHCX is the next major reform in the insurance industry. IRDAI has earlier approved 'Bima Sugam' another revolution in the insurance sector to provide an online marketplace for insurance, to help policyholders compare premiums and features of all categories of insurance products. buy insurance products including life, health, motor and travel insurance.

Role of Digital Health in India's Rural Healthcare Landscape

India’s vast rural expanse, home to more than two-thirds of the nation’s population, faces formidable challenges in accessing quality healthcare. Limited infrastructure, a shortage of qualified medical professionals, and geographic barriers create significant disparities between urban and rural healthcare delivery. Digital health solutions are emerging as a potent force in revolutionizing this landscape, promising to deliver equitable and accessible healthcare to India’s underserved rural communities.

Key Pillars of Digital Health Intervention

• Telemedicine and Remote Consultations: At the forefront of digital health, telemedicine platforms are bridging the gap between patients in remote villages and specialists residing in faraway urban centres. These platforms facilitate real-time video consultations, allowing rural patients to receive diagnoses, treatment plans, and follow-up care without the need for arduous journeys to cities. This significantly reduces travel costs, time, and the burden on rural families.
• Electronic Health Records (EHRs): Digitizing patient records is instrumental in improving care coordination and reducing medical errors. With EHRs, healthcare providers across different locations can access a patient’s medical history, ensuring continuity of care and informed decision-making. Digital records also streamline the referral process and aid in disease surveillance and outbreak management.

• Mobile Health (mHealth) Applications: The proliferation of smartphones and internet connectivity has made mHealth apps a valuable tool for rural communities. These apps provide health education, preventive care information, medication reminders, and symptom checkers, empowering individuals to take charge of their health. In particular, pregnancy tracking and maternal health apps are proving to be lifelines in remote areas.
• Remote Patient Monitoring (RPM): RPM technology allows healthcare providers to track vital signs, such as blood pressure and blood sugar, of patients with chronic diseases from afar. This proactive monitoring enables early interventions, facilitates timely adjustments to treatment plans, and reduces the risk of expensive hospitalizations.
• Point-of-Care Diagnostics: Portable diagnostic devices connected to smartphones or tablets are bringing laboratory-quality testing to remote corners of India. These devices can perform tests for infectious diseases, anaemia, and other conditions, leading to rapid diagnoses and faster treatment initiation, which is crucial in resource-limited settings.

Benefits of Digital Health for Rural India

• Improved Access to Care: Digital health transcends geographical barriers and overcomes the lack of specialists in rural areas. Patients can access essential medical services without the hardship and expense of traveling long distances.
• Enhanced Quality of Care: EHRs and telemedicine consultations with specialists support rural healthcare providers in delivering higher quality care, leading to improved patient outcomes.

• Cost Reduction: Digital health solutions reduce patient travel costs, minimize unnecessary hospitalizations, and improve efficiency in healthcare delivery, contributing to overall cost savings.
• Preventive Care and Empowerment: mHealth apps and educational resources empower rural communities to adopt healthier lifestyles, practice preventive care, and make informed decisions about their health.

Challenges and Considerations

While the transformative potential of digital health is undeniable, its widespread adoption in rural India faces hurdles:

• Digital Literacy & Adoption: Limited digital literacy and technological skills among some rural populations can hinder the uptake of digital health solutions.
• Infrastructure: Unreliable internet connectivity and electricity supply in certain areas pose challenges for telemedicine and other digital health interventions.

• Data Security and Privacy: Robust measures are needed to ensure the security and privacy of sensitive patient data in the digital realm. In this regard Government of India passed The Digital Personal Data Protection Act (DPDPA) in August 2023. DPDPA assigns restrictions and obligations to organizations that process personal data including sensitive patient data.

The Way Forward

To fully realize the benefits of digital health in improving rural healthcare in India, collaborative efforts among government, healthcare providers, technology companies, and communities are vital. Key measures include:

• Investing in Digital Infrastructure: Expanding broadband connectivity and ensuring reliable electricity supply in rural areas.
• Digital Literacy Campaigns: Educating rural communities on the use of digital tools, promoting their adoption.

• Government Initiatives: Continued support and favourable policies, including the Ayushman Bharat Digital Mission by National Health Authority (NHA), are key to scaling digital health initiatives. The Ayushman Bharat Digital Mission has the potential to transform the landscape of rural healthcare in India. Its focus on interoperability, inclusivity, and patient empowerment directly addresses the unique challenges of healthcare delivery in these regions.
• Partnerships and Capacity Building: Training rural healthcare workers in digital health technologies and fostering collaboration between healthcare providers and technology innovators.

Digital health holds the key to bridging the healthcare divide between rural and urban India. Its strategic implementation offers an unprecedented opportunity to deliver affordable, accessible, and high-quality healthcare to the doorstep of those who need it the most.

Digital Personal Data Protection Act 2023: Impact On Indian Healthcare Industry

The Digital Personal Data Protection Act, 2023 (DPDP Act) is a new law regulating personal data processing in India. It aims to protect the privacy rights of individuals and create a framework for data governance and accountability. The DPDP Act will significantly impact the Indian healthcare industry, which is still in its early stages of digital evolution. Some of the key impacts are:

• The DPDP Act will require healthcare providers and entities to obtain explicit consent from data principals (individuals whose data is processed) before collecting, using, or sharing their personal health data, which is classified as sensitive personal data under the law

• The DPDP Act will also mandate healthcare providers and entities to implement appropriate security measures, conduct data protection impact assessments, appoint data protection officers, and comply with the codes of practice and standards issued by the Data Protection Board of India

• The DPDP Act will enable data principals to access, correct, erase, port, and restrict the processing of their personal health data and seek redressal for any grievances or violations of their rights

• The DPDP Act will create new opportunities for innovation and collaboration in the healthcare industry, as it will facilitate the use of personal health data for research, public health, emergency response, and other purposes, subject to certain conditions and safeguards

Implications of Digital Personal Data Protection Act 2023 in Healthcare Sector

The Digital Personal Data Protection Act, 2023 (DPDP Act) will have various implications in the healthcare sector in India, such as:

• It will require healthcare providers and entities to adopt privacy-conscious and data-responsible practices, such as obtaining explicit consent, implementing security measures, conducting data protection impact assessments, and appointing data protection officers

• It will enhance patient trust and confidence in using their personal health data, which is classified as sensitive personal data under the law.

• It will create new opportunities for innovation and collaboration in using personal health data for research, public health, emergency response, and other purposes, subject to certain conditions and safeguards

• It will also create challenges for developing and adopting data-driven technologies, such as artificial intelligence and machine learning, which may require balancing the protection of patient privacy and the potential of these technologies.

It will interact with other existing or proposed laws and policies related to health data, such as the Ayushman Bharat Digital Mission (ABDM), which aims to create a unique health ID named ABHA and a digital health record for each person. 

Government Initiatives to Protect Patient Data

The Information Technology Act 2000 governs provisions related to Protected Health Information (PHI) and the Information Technology (Reasonable Security Practices and Procedures and Sensitive Personal Data or Information) Rules, 2011. 

Patient data, including health information, is treated as sensitive personal data or information and, under the IT Act, offers some degree of protection to the collection, disclosure, and transfer of sensitive personal data. 

Also, long before DPDP Act 2023, the Government introduced the Digital Information Security in Healthcare Act (DISHA), India’s counterpart of the Health Insurance Portability and Accountability Act (HIPAA), aimed at providing healthcare data privacy, security, confidentiality, and standardization and establishment of the National Electronic Health Authority (NeHA) and Health Information Exchanges. While this act aims to encourage the pan-India adoption of e-health standards, DISHA has not yet come into force. 

Penalties in Digital Personal Data Protection Act 2023 

Under the DPDP Act, 2023, you have the right to file a complaint with the Data Protection Board of India (DPB), which is the enforcement body established under the act, if you suspect or experience any non-compliance by a third party that collects or processes your personal data. The DPB can inquire into the complaint, direct any remedial or mitigation measures, inspect any document, summon and enforce the attendance of any person, and impose penalties for non-compliance. 

The act allows only monetary penalties for breaches or non-compliance, ranging from INR 50 crore to INR 250 crore, with a maximum penalty of INR 500 crore for significant data breaches. You can also seek compensation from the DPB for any harm caused to you due to the non-compliance by the third party. However, the act does not provide criminal liability or imprisonment for non-compliance. 

Data Principal

A key ingredient in laws in other countries is the power to impose penalties up to a particular amount as prescribed for offenses or as a percentage of total worldwide turnover, whichever is higher.

A data principal is under an obligation to not register a false or frivolous complaint with a data fiduciary or the Board, not to furnish any false particulars or suppress any material information. 

DPDP Act 2023 has introduced a penalty of up to ₹10,000/- (Rupees Ten Thousand) on the data principal for failure to comply with its proposed obligations.

The proposed DPDP Act 2023 introduces the concept of ‘Deemed Consent’, where the data principal is deemed to have given consent for processing their personal data. 

Consensual processing of personal data may be done in case of medical emergencies involving a threat to life or an immediate threat to the health of the Data Principal. In the context of such processing, a parallel may be drawn with India’s draft Health Data Management Policy by ABDM released in April 2022, which also envisages provisions relating to the processing of Personal Data in case of medical emergencies. 

Notably, the ABDM contemplates the appointment of a nominee to provide valid consent on behalf of the Data Principal in case such Data Principal becomes seriously ill or mentally incapacitated or where the Data Principal is facing a threat to life or a severe threat to health and is unable to give valid consent. 

Unlike the DPDP Act 2023, the ABDM does not propose Deemed Consent in the absence of a nominee but instead shifts the right to give valid consent on behalf of the Data Principal to an adult member of the family of the Data Principal.

Despite the recommendation under the JPC Report, the DPDP Act 2023 has kept the 'Non-Personal Data' of the individuals, such as information collected by the Government, NGOs, and other private sector entities, outside its ambit. The usage of phrases 'as it may be considered necessary' and 'as may be prescribed' can lead to administrative ambiguities. The autonomy of the Data Protection Board, which is entrusted with overseeing the protection of individual's personal data and ensuring compliance with the provisions of the law, is not reassuring. Further, the Government and its instrumentalities can retain personal data for an indefinite period irrespective of whether the purpose for which data was processed has been fulfilled. 

Conclusion

By 2030 India is projected to be the world’s third-largest economy and will have one of the world’s largest digital personal data footprints in motion and at rest. 

The DPDP 2023 Act’s essentiality shines in our strengthening role in the global order. With the G20 Presidency and multiple Free Trade and Regional Trade Agreements in place, we must find solutions for Data Free Flow with Trust and cross-border data flows.