Page 22 - Insurance Times July 2023

chase concept. In 'Pay & Chase' concept payment is made Desk Medical Audit is an important tool to detect fraud &
within the agreed turnaround time (TAT) believing that abuse in Scheme. Fraud under PM-JAY shall mean and
submitted documents are true and verifiable for treatment include any intentional deception, manipulation of facts and/
done. In case wrongdoing or manipulation is found later in or documents or misrepresentation made by a person or
submitted documents the recoveries are chased, and organization with the knowledge that the deception could
penalties are imposed as deterrent measure to ensure result in unauthorized financial or other benefit to himself/
observance of right practices by all stakeholders. The right herself or some other person/organization. It includes any
of recovery and right of imposing penalty is protected in act that may constitute fraud under any applicable law in
clauses of contract amongst hospital, state health assurance India. There may be some cases with manipulated
authority and insurer in tri-partite agreements. documents to justify package booked by the hospital and
these may go undetected during claim processing and may
MDP is set of mandatory documents defined for each be settled and paid by insurance company. Identification and
procedure/package which should mandatorily be uploaded
detection of such cases is an important function of desk
at the time of raising a preauthorization or for submitting a medical audit that helps in recovering such wrong payments.
claim after discharge of patient. These are necessary
documents to determine the validity of a booked package.
Medical records are complex in nature. Medical knowledge
Scrutiny of mandated documents as per MDP of submitted
and skill is necessary to understand such records and to find
claims either before settlement or after settlement of a
their relevance in treatment, prescribed medication,
claim is an important function of Desk Medical Audit.
diagnostic or required necessity of specialists, physicians &
anaesthetists to a diagnosed ailment. Generally, MBBS, BDS
Desk Medical Audit is a systematic review of an episode of
& other AYUSH doctors perform Desk Medical Audit. These
health care conducted on the desk of the medical auditor,
professionals shall detect integrity violations by examining
without visiting the hospital. Auditor cross verify & validate
submitted MDP documents, films & reports and shall find
in a step-by-step analysis of all-important aspects of the
whether treatment has a medical justification and that the
medical/surgical procedure performed in an empanelled
procedure booked has been done.
hospital against the explicit criteria defined in the scheme
i.e., covered beneficiary, medical condition, symptoms,
State Administration Agency & Insurers provide claim
diagnosis, medical justification of treatment, correct code
submission guidelines to the hospitals and claim processing
of package, treatment done, policy exclusion, empanelled
guidelines to claim processors (Insurer/TPAs). Minimum
hospital etc. The objective of this audit is to ascertain the
document protocol for each package/procedure is defined
order of the claim & its genuineness on booked medical
both at preauthorization level as well as at claim submission
services.
level. Wherever required Standard Treatment Guidelines
(STGs) are provided for procedures/packages.
This must be evident from submitted MDP that procedure
has been carried out and that indications provided therein
The Desk Medical Auditor should be aware of these
are suggestive of medical necessity of the treatment. Desk
guidelines, MDPs, STGs and various circulars in force before
Medical Auditor verifies all case related documents that are
initiating desk audit for transactions. The objectives of STGs
part of MDP e.g., prescription, admission note, clinical notes,
are to aid the pre-authorization and claim processing
investigation reports, daily progress notes, discharge
doctors by specifying the mandatory documentation
summary, OT notes (in case of surgery). It is pertinent to
required and specific things to look for in these documents
note that claim processors whilst processing claims check
for prescribed procedures. Desk Medical Auditor shall
individual claims, and it is difficult for them to detect pattern
of utilization or manipulation, but Desk Medical Auditor validate whether processing happened as per guidelines,
examines multiple TIDs and therefore shall be able to find STGs and submitted MDPs are suggestive of same.
such patterns. For example, use of same IVP/USG report may
not be detected in claim processing function where claim These tools enhance the skills of Desk Medical Auditors in
processor works on a single TID, but such patters should be understanding fundamental concepts of packages and their
detected in a desk audit function if a pattern is visible in stratification based on different criteria such as type of
multiple TIDs of hospital or diagnostic reports with same anesthesia, bed category on admission, surgical technique
findings are found in many TIDs of hospital. etc.

20 July 2023 The Insurance Times