Empanelment in Health Insurance: Meaning, Process & Benefits

In case anyone purchases any health insurance, it is essential to understand empanelled hospital meaning in order to ensure that they get quality medical treatment when they actually need it. Whether you are getting treatment at a hospital or visiting another health service provider, it is important to know empanelment meaning with any insurance company. The guide below discusses how it connects to cashless health insurance and why the importance of network hospitals goes beyond convenience.

What is Empanelment in Health Insurance?

Empanelment meaning in medical refers to the process whereby healthcare organisations such as hospitals, clinics, and diagnostic centres get empanelled into the network of the insurance companies. For a provider, empanelment meaning is simply that he or she has got the nod from the insurance company (or Third-Party Administrator managing the network of the insurance company) to offer their services as per the negotiated prices. This is the empanelled meaning in medical terminology.

How Does Hospital Empanelment Work in Health Insurance?

Hospital empanelment involves a series of checks and formal steps before a healthcare provider becomes part of an insurer’s network. The process generally includes:

1. Application: The hospital submits an empanelment application to the insurance company or its Third-Party Administrator (TPA).
2. Evaluation: The insurance company or TPA evaluates the hospital's infrastructure, medical facilities, equipment, staff qualifications and experience, and the quality of care provided. Most insurers also require recognised quality accreditation during evaluation.
3. Agreement Finalisation: Upon approval, the two parties agree to all the terms of the contract, which usually include negotiated prices for the treatments, billing process and services.
4. Network Inclusion: The hospital becomes a part of the network of the insurance company or TPA and is thus able to provide cashless treatments to its policyholders.

Key Benefits of Empanelment in Health Insurance

Access to Cashless Treatment: Another major advantage of empanelment is the cashless treatment option. Once you get admitted to an empanelled hospital, the payment will be made by the insurer to the hospital directly; thus, eliminating the burden of paying huge amounts of money at once, which is especially useful in emergency cases.

Access to Quality Healthcare Facilities: Insurers tend to prefer empanelled healthcare facilities that provide high-quality services to their policyholders.

Wider Coverage: A wider empanelled network gives policyholders many options, making access to healthcare facilities easier in various cities and regions, depending on the insurer and different types of health insurance you have.

Faster Claims Process: As empanelled hospitals know the insurer's procedure requirements, claims handling goes much faster and requires less documentation from the policyholder.

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How Does Hospital Empanelment Help in Cashless Health Insurance Claims?

It is indeed empanelment that makes the idea of cashless health insurance viable. With an established billing arrangement between the hospital and the insurance company, both parties can settle any expenses incurred by skipping the middleman. The process through which a policyholder makes use of the facility can be summarised as follows:

1. Choose an empanelled hospital: This means picking a hospital from the list of hospitals empanelled with your insurance company, preferably before planning for admission.
2. Pre-approval of treatment: If the treatment being planned is not an emergency, send the pre-approval form along with your medical information, an estimate of charges incurred, and information about the plan to the insurance company. The time frame set by IRDAI 2024 rules is 1 hour for planned treatment and 3 hours for emergencies.
3. Get treated without upfront payment: After getting approved by the insurance company, the hospital gives you treatment and clears the bill through the insurer; you will only have to pay for items not covered by the insurance.

Network Hospital vs Non-Network Hospital

The main difference between network and non-network hospitals is how the insurance claim is handled. Network hospitals have an arrangement with the insurer or TPA, which generally makes cashless treatment and claim coordination more straightforward. Non-network hospitals may still be used, but the policyholder may need to pay the treatment expenses first and then apply for reimbursement, subject to the policy terms.

Why Are Network Hospitals Important?

Network hospitals can make health insurance more convenient, particularly when a policyholder needs planned hospitalisation or treatment at short notice. Since the hospital already has an arrangement with the insurer or TPA, the cashless claim process can involve less upfront payment and easier coordination.

However, policyholders may choose either a network or non-network hospital depending on their circumstances. A preferred hospital may not be part of the insurer's network, or a medical emergency may require treatment at the nearest available facility. In such cases, treatment at a non-network hospital may still be covered under the policy, but the claim process and payment requirements can differ.

The choice can also depend on the type of health insurance policy. For example, the coverage structure and healthcare needs may differ between individual vs family health insurance plans, making it important to check the applicable network, cashless facility and policy terms before seeking treatment.

It is therefore useful to check cashless eligibility, reimbursement rules, pre-authorisation requirements, co-payments and covered expenses before choosing a hospital.

How Do You Check If a Hospital Is Empanelled With an Insurer?

• Visit the official site of the insurance provider.
• Go to the page where all the empanelled hospitals are listed or mentioned.
• Search for empanelled hospitals by entering your location details.
• Check whether the particular hospital you are planning to visit is empanelled for your city and insurance policy.

To Sum Up

In health insurance, empanelment is a positive outcome for both the insurer and the insured. For the insurer, it provides them with a reliable and vetted network of health-care practitioners. The insured benefits by getting access to cashless treatment and a speedy claim process, along with cost-effectiveness. This comes on the condition that you plan in accordance with your insurer's network.