Page 26 - Insurance Times July 2023

with name of patient, where it is part of MDP? One o Open Cholecystectomy without the exploration of
should find whether Ph., CO2 & HCO3 is normal in CBD
arterial value range. If Ph. is less than 7.35-7.45 it
Stratification enables price differentiation of the
indicates acidosis; if CO2 is less than 35-45 mm Hg
procedure to better accommodate the nuances of the
(normal range) it indicates alkalosis and if PO2 is less
procedure performed. For example, the procedure
than normal (80-100 mm Hg) it indicates hypoxemia. If
'incision and drainage of abscesses is split into two
HC)3 is less (22-26 m Eq/L) it indicates acidosis. This
stratified packages with a price difference of Rs 5000
report may help claim processors and auditors to find
between them.
justification of type of accommodation required to treat
o Incision and drainage of abscess under local
patient.
anesthesia
Whether detailed procedure notes, indoor case papers
o Incision and drainage of abscess under general
and indication are suggestive of booking of right
anesthesia
package and treatment being done.
Desk auditor should remain vigilant in her/his
If preauthorization is mandatory whether clinical notes verification that right code is used as per actual
including evaluation findings and planned line of procedure:
treatment is suggestive of medical procedure booked? There may be multiple procedures with different costs
Whether mandatory investigations are indicative of within a package, as seen in the above point. This is one
package/procedure booked? For example, whether area where the expertise of Desk Medical Auditor is
findings in chest X-ray, CBC, blood sugar, sepsis screen necessary to detect possible up-coding in booked
& blood culture in case of Mild respiratory distress or procedures and excessive utilization of packages where
tachypnea procedure suggestive of correct booking of gaps in cost are beneficial to the hospital.
special neonatal package for babies requiring admission
The findings of Desk Medical Audit are compiled in a logical
in NICU?
sequence and a report is submitted for each audited TID/
Hospital to insurers/administrators of the scheme. In case
Scrutiny of Packages & Procedures:
Desk Audit is for specific trigger, the auditor has to submit
Treatment package claimed should be covered under
her/his report concluding findings whether the trigger is
the scheme and should comply with the state specific
'true positive' or it is a 'false positive.'. A false positive trigger
reservation in the package master.
is processed in a normal way but in case the finding is true
In Government health insurance programme, packages positive then report is submitted to insurers/scheme
and procedure are two separate entities. These are administrators to take suitable action on it.
coded separately for better specification & related
References:
costs.
1. Medical Auditors & Investigators Guide Book for Health
Some of the packages are in fact a 'group of procedures'.
Insurance Claims by Vinay Verma & Dr Vinita Rana.
A Package is split into procedures that help in a better 2. Fraud Investigation & Medical Audit Manual- Ayushman
way to improve the granularity of the utilization of care Bharat Pradhan Mantri Jan Arogya Yojna- National
in the scheme to specify the approach to treatment, Health Authority.
treatment modality, etiology and the complication of 3. Claim adjudication manual 2.0- Ayushman Bharat-PMJAY,
the package. E.g.: National Health Authority.
o PCNL ( Percutaneous Nephrology)-Unilateral 4. National Health Benefit Package 2.2- User Guidelines,
National Health Authority.
o PCNL ( Percutaneous Nephrology)-Bilateral
5. Documentation of process for customization of Standard
o PCNL ( Percutaneous Nephrology)- Follow up
Treatment Guidelines, Ayushman Bharat-PMJAT, January
o Laparoscopic Cholecystectomy with the exploration 2021.
of CBD 6. Claim guidelines-Rajasthan State Health Agency,
Rajasthan.
o Laparoscopic Cholecystectomy without the
7. Medical Necessity Determinations: The need for a legal
exploration of CBD
structure. School of Law, Case Western Reserve University.
o Open Cholecystectomy with the exploration of CBD The Journal of Law-Medicine.

24 July 2023 The Insurance Times