Page 23 - Insurance Times July 2023

Process Flow of Desk Medical Audit: 3. Desk Medical Audit suggested by other stake holders
e.g., Anti-Fraud Unit of State Health Authority or
Desk Medical Audit is a function that happens during various
Insurers.
stages of the process of submitted claim. The audit is
primarily based on scrutiny of medical documents submitted
Check List of Desk Medical Audit: Scheme
by the hospital on TMS Portal. Source of Desk Medical Audit
can be any suspicious case triggered in system, input administrators and Insurers provide guidelines of claims
received from tele-audit or from investigation team or on including mandatory documents required as per Mandatory
findings of analytics department based on some outlier or Document Protocol for each package/procedure of the
utilization trend. The process flow of same is described Scheme. Standard Treatment Guidelines are also provided
below: that suggests for each package:
1. Random Desk Medical Audit of settled cases. Basis of Average Length of Stay
selection may be utilization of package; abuse prone Minimum qualification & desirable qualification of
procedures; or flagged hospitals. It may be done on
treating doctor
random sample of utilization to know in general
Key clinical pointers including indications and contra
whether claims practices are genuine and are supported
indications for treatment.
with required evidence as mandated in MDP.
Standard treatment workflow
2. Triggered cases which could be for specific hospital,
specific TIDs, Specific beneficiaries, specific package, Mandatory documents both at the time of
speciality or specific physician or surgeon or in preauthorization and at the time of claim submission.
combination of any of these triggers. Such triggers are
Guidelines if some mandatory documents are to be
generally flagged by:
diligently reviewed by claim processors.
a. Claim processors at Pre-Authorization level where
package booked, and documents submitted for
Desk Medical Audit is carried out to verify:
approval are suspicious.
Need of treatment.
b. Claim processors at Claim submission level based
Rightful selection of package/procedure.
where submitted documents raise doubts on
Compliance with STGs.
medical justification of package booked or where
submitted documents raise suspicion on treatment Submission of complete set of documents mandated in
actually done. MDP.

c. Tele-calling verifications by beneficiaries suggesting Triggers of suspicious transactions, outliers, suspicious
abuse by hospital or treatment has not been done utilization pattern or any suspicious fraud and abuse
or upcoding has been done.
activity pattern.
d. Beneficiary audit verification suggesting abusive Triggers informed by SAFU (State Anti-Fraud Unit) of
pattern that needs deep medical audit of submitted Scheme Administrators or by Anti-Fraud Unit of
documents of larger set of submitted claims.
Insurers.
Beneficiary may reveal that treatment booked &
Verification of case related documents in random desk
treatment done are different.
medical audit.
e. Analytics department based on observed outliers in
utilization pattern by some hospital or in specific
The following check list shall be helpful in developing required
procedure in some speciality.
skills for Desk Medical Audit:
Triggered cases provide input where deep medical audit Scrutiny of Clinical Information:
may be required at hospital. Larger set of documents remain Is the chief complaint recorded in prescription?
available in hospital for verification by the Medical Auditor. Whether procedure selected is mentioned in
Findings of this audit may require further verifications from prescription & it is appropriate with respect to chief
beneficiaries through tele-audit, beneficiary audit at hospital complaint. Whether prescription includes details of
(if treatment is ongoing) or beneficiary audit at home (if investigations, medication & package booked by the
patient is discharged.) hospital?

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