Page 25 - Insurance Times July 2023

airway security, and potency and level of anesthesia the motive. Desk Medical Auditor shall look for
recorded and available? indications, contra indications, vitals, and condition of
patient specially to validate coding to ICU ward. When
Whether patient's post anesthesia status is monitored
utilization pattern is high in hospital deep verification
or documented?
is necessary.
Whether other available stratification procedure
MDP for same package may be different if procedure
available? Whether procedure/package booked is
required is different. Desk Medical Auditor has to
correct?
validate and should ensure no upcoding goes
Are justifications to arrive at the diagnosis rational as
undetected. For example, Intensive Neonatal package
per submitted documents/reports?
for sepsis or pneumonia without complications may
Whether surgeon's name and signature available on OT require chest x-ray and septic screen whereas same
notes? Whether the surgeon possesses essential package for seizures may require more necessary
qualification for surgery performed? Whether surgeon investigation reports like serum electrolytes, blood
is empanelled by State Health Authority? sugar, serum calcium, septic screen, cerebrospinal fluid
(CSF) examination, neurosonogram,
Whether post treatment MDP documents including but
electroencephalogram to justify booking of said
not limited to post-operative x-rays, scans etc. confirms
procedure.
that the treatment was given?
MDP is different for different stages of claim submission.
Whether bar code of implant/ high end consumables in
For example, in medical oncology specialty, for CT for
procedure submitted where it is mandatory as per the
soft tissue Sarcoma, the MDP for preauthorization
MDP.
approval may require bone marrow studies, biopsy,
In bone grafting packages whether photo of donor graft
biochemistry, CBC, clinical notes with planned line of
site is provided, if mandated in MDP?
treatment, MRI/CECT thorax, pelvis or PET CT. These
Whether specific guidelines related to specific are mandatory to have approval of treatment. After
procedures/packages are adhered to? For example treatment on discharge the necessary MDP for claim
some schemes may mention specifically that in single submission may include bar code of drugs, charts of
package of Laminectomy with fusion up to three levels chemotherapy regimen, discharge summary of day
of spine will be included? Or POP cast is part of base care/inpatient care, as the case may be, reports of
package and it should not be booked as add-on package. pathology, radiology, microbiology, hematology and
biochemistry & transfusion slips.
Scrutiny of Other Documents: Desk Medical Auditor shall also validate that the
Whether generation of TID, selection of package, and settlement has been made for actual drugs/treatment.
submission of claim is within prescribed TAT? If not For example in similar case of CT for soft tissue Sarcoma
whether applicable deductions made? the combination drugs Gemcitabine & Docetaxel will
be required on defined days of cycle. The package cost
Whether live photo uploads both at the time of
is for complete cycle. It should be seen that the
admission and discharge available and uploaded?
payment is settled for drugs actually given and whether
Some schemes allow exceptions in procedures by
gap in days and maximum cycles is duly maintained.
submitting Annexures with relevant details. For
Some schemes code procedure code systematically to
example, an annexure for verification of patient by
help claim processors and medical auditors to easily
medical officer in-charge (MOIC) when biometric calculate cost of drugs for specific admission. For
verification is not possible in defined number of
example 'Gemcitabine 900 mg/m2 D1D8 Docetaxel 100
attempts. mg/m2 D8 every 21 days Maximum 6 cycles. Here drug
gemcitabine will be administrated on day one and day
Scrutiny of Medical Procedures: eight &Docetaxel will be administrated on day 8. On
STGs and MDP relevance as explained in surgical day one only cost of gemcitabine is payable whereas
procedures is equally applicable for medical procedures. on day 8 cost of both drugs is payable, if given and
evidenced by bar code of such drugs.
The stratification on type of bed/ward has cost
difference and upcoding may happen where greed is Whether machine generated ABG reports submitted

The Insurance Times July 2023 23