To know why Panel & Non-Panel Hospitals network is essential, have you ever considered the difference between Panel & Non-Panel Hospitals?
Cashless claim processing and a comprehensive list of network hospitals are the two essential items to consider when buying health insurance in Pakistan. The longer the list of panel hospitals an insurance company has, the more convenient it is to find one.
Most insurance companies enlist a network of hospitals, clinics, and medical professionals who usually charge a lower fee for their policyholders. In exchange, these panel hospitals get more patients routed to them through the insurance company’s network of insured persons.
Health insurance companies know that in case of any claims, the insured person will approach them with a substantial requirement for claim reimbursements. This means they will need to release large sums of money to the hospitals and medical professionals. These charges are often over-inflated as hospitals overcharge unaware patients for their services or unnecessary procedures. To make the situation favourable for insurance companies, they renegotiate special medical charges with the hospitals before making them a part of their panel network.
Panel hospitals usually charge a lower fee from the patients that come to them through the cashless medical insurance plan compared to those without any coverage. The hospitals benefit from a higher volume of patients and the assurance that they will get paid on time with no default.
The idea behind panel hospitals and doctors is rooted in the objective to help avoid overcharging, over-servicing, and over-use of healthcare and insurance services. With no fee benchmarks in place or reinforced, insurance companies have to specify their own guiding prices with hospitals
The doctors and hospitals on insurance company panels sign enforceable contracts and are bound to charge within the approved fee range. This ensures that claims are kept within a reasonable range while providing policyholders with the assurance that their claims will be covered and remain within their approved ranges.
Network Compared to Non-Network Hospitalization
In the case of hospitalization in a network hospital, the patient gets admitted or treated in one of the cashless insurance hospitals in the insurance company network. The patient can then submit their claim form to the insurance agent for a cashless claim.
After the cashless claim is approved, the patient can opt for treatment. The insurance company will directly bear all the approved expenses under the policy. The patient does not have to submit any bills or documents (since the hospital and insurance company sort it out amongst themselves). There is also no waiting period since no approval or special facilitation is needed. The policyholder will only bear expenses not covered under the policy.
In comparison, when a patient is admitted to a non-network hospital, they will have to pay for their entire treatment out of their own pocket. After discharge or completion of treatment, the insured party can submit all the documentation, forms, and required reports to the insurance company. The company will check all the documents and approve whatever is approved and covered under the insurance policy. The amount is then repaid to the patient after at least 10-12 days.
Scenario # 1
Mr. Ahmed has an insurance policy with cashless benefits. He needs to be admitted to a network hospital owing to a medical condition. He gets complete treatment in the hospital.
However, even though he has an insurance policy, he pays the entire bill from his pocket. Mr. Ahmed submits a claim form to his insurance company with all required original documents. The insurance staff analyzes the documents and gets the claim application processed, and approves the submitted claim according to the terms and conditions mentioned in the policy.
Scenario # 2
In another case, Mr Shamim has a cashless insurance benefit per his policy. A visiting hospital part of his insurer’s network diagnoses him with an ailment and prescribes him to get admitted to the hospital. As Mr Shamim has a cashless hospitalization benefit, he arranges for a cashless hospitalization benefit as he is entitled.
Mr Shamim gets admitted and avails the best treatment from that hospital. The hospital confirms that they don’t have to make any payments from their pockets and the hospital will claim the bill from their insurance company. After Mr Shamim is discharged, his family members approach the insurance company with the required original documents for record purposes. In this scenario, Mr Shamim’s family members only need to pay for the expenses not covered in their policy mentioned and explained to Mr Shamim at the time of the purchase.
Scenario # 3
In the third case, Mr Butt has a health insurance policy, too, and on the diagnosis of an illness, he is admitted to a non-network hospital on the advice of the doctor in that hospital. In this case, it makes no difference whether or not Mr Butt has a cashless benefit, as he is admitted to a non-network hospital.
In this, the insurance company cannot offer him any cashless benefit. He has to bear the entire expenditure and later file a claim for reimbursement. After a proper evaluation, the insurer only approves the charges feasible as per their policy. In such cases, the claim can be fully or partially approved as per the conditions of the policy
If you have a cashless claim policy, opting for treatment in a panel hospital is more practical. As a policyholder, it is advisable to have a list of the best cashless panel hospitals available with you in case of the need for sudden hospitalization.
Picking a non-network hospital should only be done in case of emergencies or if the required treatment is not available or possible in any of the network hospitals. As a policyholder, everyone wants the best treatment in the easiest way possible, and getting treatment from a network hospital provides you with exactly that.