Vision of Service
Empower and support Life and Health Insurance organizations through experiential training, intellectual inputs and medically apt cum legally sound opinions.

Disease and Treatment Protocol

X-CLAIM provides clinical expertise based holistic solutions for rational claim management addressing the objectives of customer service and containing frauds/ abuses.

Clinical audit of treatment given is achieved through a continuous process where healthcare professionals review health claims against agreed/ established standards (Standard Treatment Guidelines - STGs/ disease protocols)

A disease protocol is a structured outline of how patients with a given diagnosis are to be treated. The protocol for a given disease / symptom complex contains,

  • epidemiologic information with trends,
  • detailed information related to type of care (OPD, DayCare, IPD),
  • rational testing (laboratory & imaging) and
  • treatment options etc, which reflects best practices at the time of release and likely complications of the treatment and management thereof.

These protocols are updated periodically. They also provide insights into resources (infrastructure, medicines, clinical skill set etc) required for managing the same. From insurance perspective these protocols also provide usual/ approximate costs thereof.

Disease/ Treatment protocols for India:

India is unique when it comes its health. A heady mix of worst of third world diseases and best of life style ailments of the west; a provider population who does not have any guidelines to follow; a population that always looks for speedy 'cures' and loves multiple opinions. Protocols for Indian scenario have to be specifically created.

With a collective clinical experience of over 300 yr coupled with deep insights into physician behavior and consumer attitudes, we at X-CLAIM have created over 250 Appropriateness Protocols of commonly encountered hospitalization(s). Which help us in delivering the following:

  • Clinical Audit
  • Rational Claim Management
  • Disease Management
  • Gate keeping
  • Fraud/ abuse analytics

X-CLAIM has developed an in-house tool - Central Clinical Knowledge System (CCKS) – a rule based scoring system to facilitate STP (straight thru processing) & manual review of claims to handle large volumes in a rational manner. The tool was developed taking into account:

  • The expertise of X-CLAIM’s largely medico team with over 10 years of claim management experience
  • Over 250 disease & treatment protocols
  • Fraud/ abuse analytics

CCKS can be adapted to client IT platform to facilitate seamless integration in the client’s claim management process.
Key factors for our success lies in:

  • Providing (initial and ongoing) training to client’s claim team in the effective and efficient use of CCKS
  • Providing on a concurrent (trigger) basis Risk Based Clinical Audit of sample claims by X-CLAIMS expert team to ensure that the claims management process is working effectively.
  • Undertaking analytics on an on-going basis to detect fraud/ abuse patterns
  • Undertaking provider (diagnostic centers and hospitals) audits where suspect fraud/patterns have been highlighted