Page 24 - Insurance Times July 2023

Is the history of present illness, its onset, duration & should rest on the opinion of specialists with acceptable
progress recorded with relevant symptoms? professional evidence.
Are symptoms consistent with diagnosis? Is diagnosis in Are requisite post-treatment evidentiary documents
sync? available to confirm that treatment was given?
Are general examination and vitals noted on Determinations about whether medical services are
prescription/admission note and findings recorded? necessary for patients are not often clear-cut. Medical
science is not precise enough to determine exactly what
Whether all mandatory documents as required in
services are reasonable and necessary for diagnosis or
Minimum Document Protocol (MDP) are submitted for
treatment of an illness for every given patient.
booked package? Whether these submitted documents
justify the hospitalization & its medical necessity?
Pathology/Laboratory/Radiology reports
Do complaints fall in exclusion of the policy/scheme?
Scrutiny:
Is package booked in sync with diagnosis?
Are pathology/laboratory/radiology reports, which are
prescribed as MDP either at the time of
Scrutiny of Progress Notes from admission to
preauthorization or at the time of claim submission are
discharge: submitted?
Whether all mandatory documents required for claim
Are reports relevant to package? Whether outcome &
have been submitted/uploaded on Portal?
findings of these reports consistent with the diagnosis
Does an admission note with detailed findings on it and treatment given?
available? Whether the symptoms and diagnosis are in sync and
Are daily recorded progress reports available? Do these the diagnostic reports conclude diagnosis? The
reports capture patient's progress chronologically? package/procedure booked is in sync with diagnosis and
these reports.
Whether drugs administrated & treatment provided is
in sync with booked package? Whether administration of tests is professionally
justified and that do not expose patients to harm. It
Is the progress report signed and dated?
should, however, be remembered that treatment, in
Are specific instructions to discharge the patient and
general, is the prerogative of the treating doctor. Unless
line of treatment after discharge captured in ICP's?
evident abusive proof exists, it should not be
Does the discharge summary capture all details of contradicted.
presenting features, investigations, etiology or
causation details of condition, line of treatment given Scrutiny of Surgical Procedures:
during stay, line of treatment advised at discharge?
Whether STGs (standard treatment guidelines)
Whether these IPDs and other clinical notes and prescribed for the procedure are followed? Whether
diagnostic reports justify package booked? Desk Medical mandatory MDP submitted? Are these indicatives of
Auditor should remember that at times the clinical treatment booked and treatment being done?
condition of the patient beneficiary may require a
Is procedure elective or emergency in nature? Whether
different line of treatment.
admission documents and prescription suggestive of
It is a settled law that professional control on the line same?
of treatment is prerogative of treating doctor. The
Is pre-operative profile relevant to package, age & co-
doctor uses specialist knowledge and experience and morbidities available?
clinical judgement, and the patient's views and
Whether pre and post-operative diagnosis is duly
understanding of their condition, to identify which
recorded?
investigations and treatment are likely to result in
Whether pre-anesthesia assessment by qualified
overall benefit for patient. The selection of and choice
anesthesiologist available?
between treatments is related to clinical expertise and
to the patient's consent. Only in the case of abusive Whether details of recorded monitoring of heart rate,
intent this area should be scrutinized. If scrutinized it cardiac rhythm, respiratory rate, BP, O2 saturation,

22 July 2023 The Insurance Times