AN IMPORTANT TOOL TO DETECT INTEGRITY VIOLATIONS IN GOVERNMENT HEALTH INSURANCE PROGRAMMES

Health insurance schemes are expanding access of health care services since launch of Government of India’s flagship health insurance programme, ‘Ayushman Bharat-PMJAY’ in 2018. As India navigates through the health & financial impact of COVID-19, every State is focusing to provide tertiary and secondary care to its vulnerable population through State Health Insurance Schemes. This has transformed the landscape of health care delivery and its finance through health insurance policies. Participation of both public and private hospitals in these health insurance schemes has made care affordable and accessible to most vulnerable and poor population of the country since these schemes are financed by States. Awareness programs for these schemes have increased utilization of care. One common challenge for these popular schemes is constant threat of integrity violations. Intentional fraud, abuse and wastage in such schemes not only impact it financially but it often leads to endangering the health of poor beneficiaries. Any tax funded scheme cannot absorb the cost of abuse and wastage and tools that detect manipulations and abuses early are necessary for efficient claim management processes of such schemes. One important tool to detect integrity violations is Desk Medical Audit.

Government health insurance schemes operate on cashless and paperless models. In a cashless model the entitled beneficiary gets treatment free in empaneled hospital and patient has not to pay for treatment cost. In the paperless model the documents for reimbursement of treatment cost of entitled beneficiaries are uploaded by the care providing hospital on TMS Portal-Transaction Management System (TMS) immediately on discharge of patients. No papers need to be exchanged otherwise to make claim. Submission of necessary documents on TMS Portal is submission of documents to all concerned parties Another important feature of government schemes is that these operate on ‘TAT Model’. In TAT model reimbursement of treatment cost is made to hospitals generally in 15 days’ time limit. Hospitals are required to upload necessary documents for each health episode on TMS Portal, as per minimum document protocol (MDP) for package booked. TAT model operates on pay and chase concept. In ‘Pay & Chase’ concept payment is made within the agreed turnaround time (TAT) believing that submitted documents are true and verifiable for treatment done. In case wrongdoing or manipulation is found later in submitted documents the recoveries are chased, and penalties are imposed as deterrent measure to ensure observance of right practices by all stakeholders. The right of recovery and right of imposing penalty is protected in clauses of contract amongst hospital, state health assurance authority and insurer in tri-partite agreements.

MDP is set of mandatory documents defined for each procedure/package which should mandatorily be uploaded at the time of raising a preauthorization or for submitting a claim after discharge of patient. These are necessary documents to determine the validity of a booked package.Scrutiny of mandated documents as per MDP of submitted claims either before settlement or after settlement of a claim is an important function of Desk Medical Audit.

Desk Medical Auditis a systematic review of an episode of health care conducted on the desk of the medical auditor, without visiting the hospital. Auditor cross verify & validatein a step-by-step analysis of all-important aspects of the medical/surgical procedure performed in an empanelled hospital against the explicit criteria defined in the scheme i.e., covered beneficiary, medical condition, symptoms, diagnosis, medical justification of treatment, correct code of package, treatment done, policy exclusion, empanelled hospital etc. The objective of this audit is to ascertain the order of the claim & its genuineness on booked medical services. This must be evident from submitted MDP that procedure has been carried out and that indications provided therein are suggestive of medical necessity of the treatment. Desk Medical Auditor verifies all case related documents that are part of MDP e.g., prescription, admission note, clinical notes, investigation reports, daily progress notes, discharge summary, OT notes (in case of surgery). It is pertinent to note that claim processors whilst processing claims check individual claims, and it is difficult for them to detect pattern of utilization or manipulation, but Desk Medical Auditor examines multiple TIDs and therefore shall be able to find such patterns. For example, use of same IVP/USG report may not be detected in claim processing function where claim processor works on a single TID, but such patters should be detected in a desk audit function if a pattern is visible in multiple TIDs of hospital or diagnostic reports with same findings are found in many TIDs of hospital.

Desk Medical Audit is an important tool to detect fraud & abuse in Scheme. Fraud under PM-JAY shall mean and include any intentional deception, manipulation of facts and/or documents or misrepresentation made by a person or organization with the knowledge that the deception could result in unauthorized financial or other benefit to himself/herself or some other person/organization. It includes any act that may constitute fraud under any applicable law in India.There may be some cases with manipulated documents to justify package booked by the hospital and these may go undetected during claim processing and may be settled and paid by insurance company. Identification and detection of such cases is an important function of desk medical audit that helps in recovering such wrong payments.

Medical records are complex in nature. Medical knowledge and skill is necessary to understand such records and to find their relevance in treatment, prescribed medication, diagnostic or required necessity of specialists, physicians & anaesthetists to a diagnosed ailment.Generally, MBBS, BDS & other AYUSH doctors perform Desk Medical Audit. These professionals shall detect integrity violationsby examining submitted MDP documents, films & reportsand shall find whether treatment has a medical justification and that the procedure booked has been done. State Administration Agency & Insurers provide claim submission guidelines to the hospitals and claim processing guidelines to claim processors (Insurer/TPAs). Minimum document protocol for each package/procedure is defined both at preauthorization level as well as at claim submission level. Wherever required Standard Treatment Guidelines (STGs) are provided for procedures/packages.

The Desk Medical Auditor should be aware of these guidelines, MDPs, STGs and various circulars in force before initiating desk audit for transactions. The objectives of STGs are to aid the pre-authorization and claim processing doctors by specifying the mandatory documentation required and specific things to look for in these documents for prescribed procedures. Desk Medical Auditor shall validate whether processing happened as per guidelines, STGs and submitted MDPs are suggestive of same.

These tools enhance the skills of Desk Medical Auditors in understanding fundamental concepts of packages and their stratification based on different criteria such as type of anesthesia, bed category on admission, surgical technique etc.

Process Flow of Desk Medical Audit:

Desk Medical Audit is a function that happens during various stages of the process of submitted claim. The audit is primarily based on scrutiny of medical documents submitted by the hospital on TMS Portal. Source of Desk Medical Audit can be any suspicious case triggered in system, input received from tele-audit or from investigation team or on findings of analytics department based on some outlier or utilization trend. The process flow of same is described below:

1. Random Desk Medical Audit of settled cases. Basis of selection may be utilization of package; abuse prone procedures; or flagged hospitals. It may be done on random sample of utilization to know in general whether claims practices are genuine and are supported with required evidence as mandated in MDP.
2. Triggered caseswhich could be for specific hospital, specific TIDs, Specific beneficiaries, specific package, speciality or specific physician or surgeon or in combination of any of these triggers. Such triggers are generally flagged by:
   1. Claim processors at Pre-Authorization level where package booked, and documents submitted for approval are suspicious.
   2. Claim processors at Claim submission level based where submitted documents raise doubts on medical justification of package booked or where submitted documents raise suspicion on treatment actually done.
   3. Tele-calling verifications by beneficiaries suggesting abuse by hospital or treatment has not been done or upcoding has been done.
   4. Beneficiary audit verification suggesting abusive pattern that needs deep medical audit of submitted documents of larger set of submitted claims. Beneficiary may reveal that treatment booked & treatment done are different.
   5. Analytics department based on observed outliers in utilization pattern by some hospital or in specific procedure in some speciality.

Triggered cases provide input where deep medical audit may be required at hospital. Larger set of documents remain available in hospital for verification by the Medical Auditor. Findings of this audit may require further verifications from beneficiaries through tele-audit, beneficiary audit at hospital (if treatment is ongoing) or beneficiary audit at home (if patient is discharged.)

3. Desk Medical Audit suggested by other stake holders e.g., Anti-Fraud Unit of State Health Authority or Insurers.

Check List of Desk Medical Audit:Scheme administrators and Insurers provide guidelines of claims including mandatory documents required as per Mandatory Document Protocol for each package/procedure of the Scheme. Standard Treatment Guidelines are also provided that suggests for each package:

• Average Length of Stay
• Minimum qualification & desirable qualification of treating doctor
• Key clinical pointers including indications and contra indications for treatment.
• Standard treatment workflow
• Mandatory documents both at the time of preauthorization and at the time of claim submission.
• Guidelines if some mandatory documents are to be diligently reviewed by claim processors.

Desk Medical Audit is carried out to verify:

• Need of treatment.
• Rightful selection of package/procedure.
• Compliance with STGs.
• Submission of complete set of documents mandated in MDP.
• Triggers of suspicious transactions, outliers, suspicious utilization pattern or any suspicious fraud and abuse activity pattern.
• Triggers informed by SAFU (State Anti-Fraud Unit) of Scheme Administrators or by Anti-Fraud Unit of Insurers.
• Verification of case related documents in random desk medical audit.

The following check list shall be helpful in developing required skills for Desk Medical Audit:

Scrutiny of Clinical Information:

• Isthe chief complaint recorded in prescription? Whether procedure selected is mentioned in prescription & it is appropriate w.r.t. chief complaint. Whether prescription includes details of investigations, medication & package booked by the hospital?
• Is the history of present illness, its onset, duration & progress recorded with relevant symptoms?
• Are symptoms consistent with diagnosis? Is diagnosis in sync?
• Are general examination and vitals noted on prescription/admission note and findings recorded?
• Whether all mandatory documents as required in Minimum Document Protocol (MDP) are submitted for booked package? Whether these submitted documents justify the hospitalization & its medical necessity?
• Docomplaints fall in exclusion of the policy/scheme?
• Is package booked in sync with diagnosis?

Scrutiny of Progress Notes from admission to discharge:

• Whether all mandatory documents required for claim have been submitted/uploaded on Portal?
• Doesan admission note with detailed findings on it available?
• Are daily recorded progress reports available? Do these reports capture patient’s progress chronologically? Whether drugs administrated & treatment provided is in sync with booked package?
• Is the progress report signed and dated?
• Are specific instructions to discharge the patient and line of treatment after discharge captured in ICP’s?
• Does the discharge summary capture all details of presenting features, investigations, etiology or causation details of condition, line of treatment given during stay, line of treatment advised at discharge?
• Whether these IPDs and other clinical notes and diagnostic reports justify package booked? Desk Medical Auditor should remember that at times the clinical condition of the patient beneficiary may require a different line of treatment.
• It is a settled law that professional control on the line of treatment is prerogative of treating doctor. The doctor uses specialist knowledge and experience and clinical judgement, and the patient’s views and understanding of their condition, to identify which investigations and treatment are likely to result in overall benefit for patient. The selection of and choice between treatments is related to clinical expertise and to the patient’s consent. Only in the case of abusive intent this area should be scrutinized. If scrutinized it should rest on the opinion of specialists with acceptable professional evidence.
• Are requisite post-treatment evidentiary documents available to confirm that treatment was given?
• Determinations about whether medical services are necessary for patients are not often clear-cut. Medical science is not precise enough to determine exactly what services are reasonable and necessary for diagnosis or treatment of an illness for every given patient.

Pathology/Laboratory/Radiology reports Scrutiny:

• Are pathology/laboratory/radiology reports, which are prescribed as MDP either at the time of preauthorization or at the time of claim submission are submitted?
• Are reports relevant to package? Whether outcome & findings of these reports consistent with the diagnosis and treatment given?
• Whether the symptoms and diagnosis are in sync and the diagnostic reports conclude diagnosis? The package/procedure booked is in sync with diagnosis and these reports.
• Whether administration of tests is professionally justified and that do not expose patients to harm. It should,however, be remembered that treatment, in general, is the prerogative of the treating doctor. Unless evident abusive proof exists, it should not be contradicted.

Scrutiny of Surgical Procedures:

• Whether STGs (standard treatment guidelines) prescribed for the procedure are followed? Whether mandatory MDP submitted? Are these indicatives of treatment booked and treatment being done?
• Is procedure elective or emergency in nature? Whether admission documents and prescription suggestive of same?
• Is pre-operative profile relevant to package, age & co-morbidities available?
• Whether pre and post-operative diagnosis is duly recorded?
• Whether pre-anesthesia assessment by qualified anesthesiologist available?
• Whether details of recorded monitoring of heart rate, cardiac rhythm, respiratory rate, BP, O2 saturation, airway security, and potency and level of anesthesia recorded and available?
• Whether patient’s post anesthesia status is monitored or documented?
• Whether other available stratificationprocedure available? Whether procedure/package booked is correct?
• Are justifications to arrive at the diagnosis rational as per submitted documents/reports?
• Whether surgeon’s name and signature available on OT notes? Whether the surgeon possesses essential qualification for surgery performed? Whether surgeon is empanelled by State Health Authority?
• Whether post treatment MDP documents including but not limited to post-operative x-rays, scans etc. confirms that the treatment was given?
• Whether bar code of implant/ high end consumables in procedure submitted where it is mandatory as per the MDP.
• In bone grafting packages whether photo of donor graft site is provided, if mandated in MDP?
• Whether specific guidelines related to specific procedures/packages are adhered to? For example some schemes may mention specifically that in single package of Laminectomy with fusion up to three levels of spine will be included? Or POP cast is part of base package and it should not be booked as add-on package.

Scrutiny of Other Documents:

• Whether generation of TID, selection of package, and submission of claim is within prescribed TAT? If not whether applicable deductions made?
• Whether live photo uploads both at the time of admission and discharge available and uploaded?
• Some schemes allow exceptions in procedures by submitting Annexures with relevant details. For example, an annexure for verification of patient by medical officer in-charge (MOIC) when biometric verification is not possible in defined number of attempts.

Scrutiny of Medical Procedures:

• STGs and MDP relevance as explained in surgical procedures is equally applicable for medical procedures.
• The stratification on type of bed/ward has cost difference and upcoding may happen where greed is the motive. Desk Medical Auditor shall look for indications, contra indications, vitals, and condition of patient specially to validate coding to ICU ward. When utilization pattern is high in hospital deep verification is necessary.
• MDP for same package may be different if procedure required is different. Desk Medical Auditor has to validate and should ensure no upcoding goes undetected. For example, Intensive Neonatal package for sepsis or pneumonia without complications may require chest x-ray and septic screen whereas same package for seizures may require more necessary investigation reports like serum electrolytes, blood sugar, serum calcium, septic screen, cerebrospinal fluid (CSF) examination, neurosonogram, electroencephalogram to justify booking of said procedure.
• MDP is different for different stages of claim submission. For example, in medical oncology specialty, for CT for soft tissue Sarcoma, the MDP for preauthorization approval may require bone marrow studies, biopsy, biochemistry, CBC, clinical notes with planned line of treatment, MRI/CECT thorax, pelvis or PET CT. These are mandatory to have approval of treatment. After treatment on discharge the necessary MDP for claim submission may include bar code of drugs, charts of chemotherapy regimen, discharge summary of day care/inpatient care, as the case may be, reports of pathology, radiology, microbiology, hematology and biochemistry & transfusion slips.
• Desk Medical Auditor shall also validate that the settlement has been made for actual drugs/treatment. For example in similar case of CT for soft tissue Sarcoma the combination drugs Gemcitabine & Docetaxel will be required on defined days of cycle. The package cost is for complete cycle. It should be seen that the payment is settled for drugs actually given and whether gap in days and maximum cycles is duly maintained. Some schemes code procedure code systematically to help claim processors and medical auditors to easily calculate cost of drugs for specific admission. For example ‘Gemcitabine 900mg/m2 D1D8 Docetaxel 100 mg/m2 D8 every 21 days Maximum 6 cycles. Here drug gemcitabine will be administrated on day one and day eight &Docetaxel will be administrated on day 8. On day one only cost of gemcitabine is payable whereas on day 8 cost of both drugs is payable, if given and evidenced by bar code of such drugs.
• Whether machine generated ABG reports submitted with name of patient, where it is part of MDP? One should find whether Ph., CO2 & HCO3 is normal in arterial value range. If Ph. is less than 7.35-7.45 it indicates acidosis; if CO2 is less than 35-45 mmHg (normal range) it indicates alkalosis and if PO2 is less than normal (80-100 mm Hg) it indicates hypoxemia. If HC)3 is less (22-26 m Eq/L) it indicates acidosis. This report may help claim processors and auditors to find justification of type of accommodation required to treat patient.
• Whether detailed procedure notes, indoor case papers and indication are suggestive of booking of right package and treatment being done.
• If preauthorization is mandatory whether clinical notes including evaluation findings and planned line of treatment is suggestive of medical procedure booked? Whether mandatory investigations are indicative of package/procedure booked? For example, whether findings in chest X-ray, CBC, blood sugar, sepsis screen & blood culture in case of Mild respiratory distress or tachypnea procedure suggestive of correct booking of special neonatal package for babies requiring admission in NICU?

Scrutiny of Packages & Procedures:

• Treatment package claimed should be covered under the scheme and should comply with the state specific reservation in the package master.
• In Government health insurance programme, packages and procedure are two separate entities. These are coded separately for better specification & related costs.
• Some of the packages are in fact a ‘group of procedures’.
• A Package is split into procedures that help in a better way to improve the granularity of the utilization of care in the scheme to specify the approach to treatment, treatment modality, etiology and the complication of the package. E.g.:
  • PCNL ( Percutaneous Nephrology)-Unilateral
  • PCNL ( Percutaneous Nephrology)-Bilateral
  • PCNL ( Percutaneous Nephrology)- Follow up
  • Laparoscopic Cholecystectomy with the exploration of CBD
  • Laparoscopic Cholecystectomy without the exploration of CBD
  • Open Cholecystectomy with the exploration of CBD
  • Open Cholecystectomy without the exploration of CBD
• Stratification enables price differentiation of the procedure to better accommodate the nuances of the procedure performed. For example, the procedure ‘incision and drainage of abscesses is split into two stratified packages with a price difference of Rs 5000 between them.
  • Incision and drainage of abscess under local anesthesia
  • Incision and drainage of abscess under general anesthesia

Desk auditor should remain vigilant in her/his verification that right code is used as per actual procedure:

• There may be multiple procedures with different costs within a package, as seen in the above point. This is one area where the expertise of Desk Medical Auditor is necessary to detect possible up-coding in booked procedures and excessive utilization of packages where gaps in cost are beneficial to the hospital.

The findings of Desk Medical Audit are compiled in a logical sequence and a report is submitted for each audited TID/Hospital to insurers/administrators of the scheme. In case Desk Audit is for specific trigger, the auditor has to submit her/his report concluding findings whether the trigger is ‘true positive’ or it is a ‘false positive.’. A false positive trigger is processed in a normal way but in case the finding is true positive then report is submitted to insurers/scheme administrators to take suitable action on it.

Authors

Dr Vaishali Pradhan, BDS: Has more than 3 years’ experience both in the clinical side and in the non-clinical side handling claim process and desk medical audit in ‘MukhyamantriChiranjivi Swasthya Bima Yojna’, the flagship health insurance scheme of Government of Rajasthan. She is Team Leader of Desk Medical Audit in GHPL TPA Limited in Jaipur Project Office.

&

Vinay Verma, M.com, F.I.I.I, ACS, PGDMM,PGDIM: Former Dy General Manager in Oriental Insurance Company Limited. More than 35 years of experience in handling health insurance. He was a member of important Forums like FICCI, C.I.I, PPN in Health Insurance. He was a member of the committee of National Health Authority & IRDAI on Anti-Fraud Guidelines. He has to his credit the most prestigious S.K Desai Award and Dr Subramanium Award for his research papers in Health and Auto Insurance. He is the author of many articles in insurance in national and international magazines. He is a professional trainer with vast teaching experience in School of Insurance Studies, National Law University, National Insurance Academy, Insurance Institute of India, Staff college of Oriental Insurance Company Limited.