How Health Insurers Track Claims & Information
1. Digital Claim Coding Systems
- ICD Codes (International Classification of Diseases)
- Example: *E11.65 = Type 2 diabetes with hyperglycemia*
- CPT Codes (Current Procedural Terminology)
- Example: *80053 = Comprehensive metabolic panel*
Tracking Method:
✔ Automated flagging of mismatched codes
✔ Cross-checking with treatment norms
2. National Health Databases
| Database | What Insurers Check |
|---|---|
| National Health Stack | Past insurance claims |
| PMJAY/ABHA Records | Government scheme usage |
| Hospital EMR Systems | Treatment consistency |
💡 *79% of insurers now use AI to scan these databases in real-time*
3. Pharmacy & Diagnostic Networks
- Medicines: Tracked via:
- Pharmacy Council of India numbers
- Drug batch verification
- Tests: Monitored through:
- NABL-accredited lab reports
- Reference range analysis
Example: Insurers reject claims if:
❌ Blood test values are impossible (e.g., HbA1c = 20%)
❌ Expensive drugs prescribed without supporting diagnosis
5 Key Tracking Technologies Used
| Technology | Purpose | Used By |
|---|---|---|
| Blockchain | Prevent fake bills | HDFC Ergo, ICICI Lombard |
| AI Image Recognition | Verify scan reports | Star Health, Max Bupa |
| Geo-tagging | Confirm hospitalization | All major insurers |
| Telematics | Monitor health apps | Aditya Birla, Niva Bupa |
| Predictive Modeling | Flag suspicious patterns | SBI General, Care Health |
What Insurers Track Specifically
For Hospital Claims:
✔ Admission/discharge timestamps
✔ Procedure-duration benchmarks
✔ Medicine-dose appropriateness
For OPD Claims:
✔ Prescription validity periods
✔ Doctor registration verification
✔ Test-result correlations
For Preventive Care:
✔ Annual check-up intervals
✔ Vaccination schedules
✔ Wellness program participation
FAQs About Insurer Tracking
1. Can insurers access my medical history?
✅ Yes, but only:
- With your consent at claim time
- From hospitals/labs you’ve used
2. How do they detect fake bills?
Through:
- GST number verification
- Hospital stamp analysis
- Treatment date cross-checks
3. Do they monitor my fitness tracker data?
❌ Not without permission – But wellness programs may require sharing
4. How long do insurers keep records?
7-10 years as per IRDAI guidelines
5. Can I opt out of tracking?
Only for:
- Wellness programs
- Optional telematics
- Not for essential claim verification
3 Ways to Ensure Smooth Tracking
- Maintain Consistency
- Match prescriptions with tests
- Keep treatment timelines logical
- Use Network Providers
- Cashless claims track automatically
- Update Personal Details
- Correct mobile/email for real-time alerts