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Group Four

Frauds in Mass HealthPreventionDetectionCorrection

The PDC approach

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Fraud in Mass Health

Why?Geographical spread

Nature of business (Smart cards…smarter frauds)

Sarkari Paisaa…hamara adhikaar.

Break even post empanelment.

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A stich in time saves nine: Prevention

Empanelment strategy Define numbers Hub spoke effect Quality management system ( MBBS vs non

MBBS)

Enrollment strategy Non OTC (technological solution) Audit (frequency, learnings,

punishments/rewards)

Penalizing bad, but not recognizing good

4

What & who to investigate

Triggers

Frequency of triggers ( daily, weekly, periodical)

Approach of Investigation ( High moral stand..no)

Post investigation approach Showcause notice, blocking TID’s, depanelment

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Treatment blocked/Claimed

Data synchronization

Triggers Data analysis Auto SMS to investigator

Verification done within 24hrs Field/Hospital Audit

Authentication by Doctor’s panelAuthentication by Doctor’s panel

Representation at SNA

De-empanelment If found guilty

Continuance with RSBY

If found genuine

Field verificationBy SNA

Indecisive If found guiltyIf found genuine

Beneficiary complaint to SNA Call Canter

Field/Hospital verification with

Local Administration

Report to SNA within 48 hrs Report to SNA

Audit Process

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Triggers

Disease and Hospital stay matrix Surgical vs Medical cases Spike – High value claims High footfall from distant Distts Same card – Multiple claims

Weekly & Monthly triggers raised for Audit

Blocks more than Bed capacity. Same patient – Multiple blocks Same patient – Multiple admissions Difference between block and claims less than 6 hours Spike - No of Blocks Daily

Triggers - 0301

Triggers - 0303

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Patient was blocked for fissurectomy and haemorrhoidectomy, Angina , tropical infection complication with enteric fever on a same day.

This is not possible because patient should not be operated with these multiple serious medical problems.

This may cause for patient death.

Same Patients – Multiple Blocks

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It has been observed that exceptionally high number of repeat admission in short span.

Hospital advising patients to over again for post treatment examination and blocking as new admission.

Same patient - Multiple admissions

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Government support

Advisory being converted into tender clause

The enrollment software being standardized Non use of non website data No gap between capture of biometrics and issue

Empanelment numbers in tender QMS in five states ( in Pilot districts)

FIR to be lodged by state govt against depaneled hospitals

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Thank You