Page 21 - Insurance Times July 2023

Desk Medical Audit

An Important Tool to

Detect Integrity

Violations in

Government Health

Vinay Verma Dr Vaishali Pradhan
Insurance M.com, F.I.I.I, ACS, Team Leader of Desk Medical
PGDMM,PGDIM: Former Dy Audit in GHPL TPA Limited in
General Manager in Oriental Jaipur Project Office
Programmes Insurance Company Limited.

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.

ealth insurance schemes are expanding access claim management processes of such schemes. One
H of health care services since launch of important tool to detect integrity violations is Desk Medical
Audit.
Government of India's flagship health insurance
programme, 'Ayushman Bharat-PMJAY' in
2018. As India navigates through the health & financial Government health insurance schemes operate on cashless
impact of COVID-19, every State is focusing to provide and paperless models. In a cashless model the entitled
tertiary and secondary care to its vulnerable population beneficiary gets treatment free in empaneled hospital and
through State Health Insurance Schemes. This has patient has not to pay for treatment cost. In the paperless
transformed the landscape of health care delivery and its model the documents for reimbursement of treatment cost
finance through health insurance policies. Participation of of entitled beneficiaries are uploaded by the care providing
both public and private hospitals in these health insurance hospital on TMS Portal-Transaction Management System
schemes has made care affordable and accessible to most (TMS) immediately on discharge of patients. No papers need
vulnerable and poor population of the country since these to be exchanged otherwise to make claim. Submission of
schemes are financed by States. necessary documents on TMS Portal is submission of
documents to all concerned parties Another important
Awareness programs for these schemes have increased feature of government schemes is that these operate on
utilization of care. One common challenge for these popular 'TAT Model'.
schemes is constant threat of integrity violations. Intentional
fraud, abuse and wastage in such schemes not only impact In TAT model reimbursement of treatment cost is made to
it financially but it often leads to endangering the health of hospitals generally in 15 days' time limit. Hospitals are
poor beneficiaries. Any tax funded scheme cannot absorb required to upload necessary documents for each health
the cost of abuse and wastage and tools that detect episode on TMS Portal, as per minimum document protocol
manipulations and abuses early are necessary for efficient (MDP) for package booked. TAT model operates on pay and
The Insurance Times July 2023 19