Network and Non-Network Hospitals
It is essential to have access to quality healthcare during medical emergencies or planned treatments. With the consistent rise in healthcare costs, finding affordable healthcare facilities is difficult, especially in suburban cities without proper medical coverage.
Families and individuals belonging to middle-class or lower-middle-class income groups suffer financially without adequate insurance. However, if you invest in health insurance, you can easily avail of cashless treatments in both network and non-network hospitals.
Extraordinary Facts
The General Insurance Council announced the 'Cashless Everywhere' initiative in January, allowing health insurance policyholders to avail treatment at any hospital, not just those listed in their policy.
What Are Network Hospitals?
All hospitals associated with a health insurance company fall under 'Network Hospitals'. When you seek medical treatment from a network hospital, your expenses are settled directly between the insurer and the hospital.
What Are Non-Network Hospitals?
A non-network hospital is a hospital that does not fall under the network of your health insurance provider. On seeking medical treatment from a non-network hospital, you have to pay the bill out of pocket first and file a reimbursement claim with your insurer later.
Network vs. Non-Network Hospitals: A Comparison
| Basis | Network Hospital | Non-Network Hospital |
|---|---|---|
| Definition | Hospitals connected with the health insurance company are called network hospitals. | Hospitals not listed by health insurers are known as non-network hospitals. |
| Contract Agreement | Network hospitals have a formal agreement with the insurance providers. | Non-network hospitals do not have a formal agreement or contract with the insurance provider. |
| Benefits | Services are received at reduced or pre-negotiated rates. | Higher out-of-pocket costs may be incurred for services. |
| Billing Process | The health insurer usually settles bills directly with the hospital. | You typically pay the bill upfront and seek reimbursement from your insurer later. |
| Listing | Network hospitals are usually listed in the insurance plan's provider directory. | Non-network hospitals are not listed in the insurance provider's directory. |
| Insurance Coverage | Comprehensive coverage is provided for rendered services. | Coverage may be limited or subject to different reimbursement rates. |
| Waiting Period | No waiting period is applied; bills are settled immediately. | Yes, an approximately 10-15 day waiting period is applied for reimbursement. |
| How does it work? | With a network hospital, you file the claim, and the insurance company settles the bill directly with the hospital. | For emergencies, bills are settled directly. However, for planned hospitalisation, you pay upfront and then apply for reimbursement. The company will then reimburse the lump sum amount paid for hospitalisation. |
How Does Network Hospitalization Work?
Now that we know what network hospitals are, let us understand how cashless hospitalization and claim settlement work.
Mr. A, advised by his doctors, has to undergo preventive surgery. Searching for network hospitals on his health insurer's panel, he found a suitable one near his residence that offered the required treatment. On admission, Mr. A and his family get in touch with the TPA desk at the hospital.
The TPA acts as a mediator between the policyholder and the hospital, ensuring a smooth cashless claim settlement process. The hospitalization and treatment expenses are paid by the insurer as per Mr. A's health policy.
How Does Non-Network Hospitalization Work?
On the other hand, Mr. B was admitted to a non-network hospital. In this scenario, he will receive the required treatment, get discharged, pay the hospital bills out-of-pocket, collect all important documents, and file a reimbursement claim later.
In the case of a non-network hospital, claim processes are somewhat more tedious and time-consuming compared to network hospitals. A common challenge policyholders face is a higher risk of partial claim settlement or complete rejection for non-network hospitalization.
Concluding Note
It is recommended to opt for health policies with a vast list of network hospitals. Investing in a health insurance plan with cashless hospitalization facilities in network hospitals is necessary to safeguard your financial health. Having a TPA handle the paperwork is a smart move as you focus on rest and recovery.
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