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1 Group Four Frauds in Mass Health Prevention Detection Correction The PDC approach.

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Presentation on theme: "1 Group Four Frauds in Mass Health Prevention Detection Correction The PDC approach."— Presentation transcript:

1 1 Group Four Frauds in Mass Health Prevention Detection Correction The PDC approach

2 2 Fraud in Mass Health Why? Geographical spread Nature of business (Smart cards…smarter frauds) Sarkari Paisaa…hamara adhikaar. Break even post empanelment.

3 3 A stich in time saves nine: Prevention Empanelment strategy Define numbers Hub spoke effect Quality management system ( MBBS vs non MBBS) Enrollment strategy Non OTC (technological solution) Audit (frequency, learnings, punishments/rewards) Penalizing bad, but not recognizing good

4 4 What & who to investigate Triggers Frequency of triggers ( daily, weekly, periodical) Approach of Investigation ( High moral Post investigation approach Showcause notice, blocking TIDs, depanelment

5 5 Treatment blocked/Claimed Data synchronization Triggers Data analysisAuto SMS to investigator Verification done within 24hrsField/Hospital Audit Authentication by Doctors panel Representation at SNA De-empanelment If found guilty Continuance with RSBY If found genuine Field verification By SNA Indecisive If found guilty If found genuine Beneficiary complaint to SNA Call Canter Field/Hospital verification with Local Administration Report to SNA within 48 hrsReport to SNA Audit Process

6 6 Triggers Disease and Hospital stay matrix Surgical vs Medical cases Spike – High value claims High footfall from distant Distts Same card – Multiple claims Weekly & Monthly triggers raised for Audit Blocks more than Bed capacity. Same patient – Multiple blocks Same patient – Multiple admissions Difference between block and claims less than 6 hours Spike - No of Blocks Daily Triggers - 0301 Triggers - 0303

7 7 Patient was blocked for fissurectomy and haemorrhoidectomy, Angina, tropical infection complication with enteric fever on a same day. This is not possible because patient should not be operated with these multiple serious medical problems. This may cause for patient death. Same Patients – Multiple Blocks URN Name, Gender Date of Admission Date of Discharge AmountCategoryFinal Diagnosis 00065421095392631 Nanku Ram, Male 08-Nov-1015-Nov-1011,250GENERAL Fissurectomy and Haemorrhoidectomy 00065421095392631 Nanku Ram, Male 08-Nov-1015-Nov-102,000 IL- Cardiac iIlness (Non interventional illness) IL-Angina 00065421095392631 Nanku Ram, Male 08-Nov-1015-Nov-10883.25IL - Infectious disease IL-Tropical infection with complication 00065421095392631 Nanku Ram, Male 08-Nov-1015-Nov-10750IL - Infectious diseaseEnteric Fever 00065421095392631 Nanku Ram, Male 02-Dec-1006-Dec-101,384IL- Respiratory illness IL-Pnemonitis with COMPLICATION 00065421095392631 Nanku Ram, Male 02-Dec-1006-Dec-103,915 IL- Cardiac iIlness (Non interventional illness) IL-Arrhythmias

8 8 It has been observed that exceptionally high number of repeat admission in short span. Hospital advising patients to over again for post treatment examination and blocking as new admission. Same patient - Multiple admissions URN Date of Admission Date of Discharge AmountFinal DiagnosisPatient Details 0006067124152690401-Aug-1004-Aug-10875IL-Acute excerbration of COPDJesingbhai 0006067124152690401-Aug-1004-Aug-103,000Enteric FeverJesingbhai 0006067124152690424-Aug-1026-Aug-104,500IL-Status asthmaticsJesingbhai 0006067124152690406-Sep-1013-Sep-10720IL-LBAJesingbhai 0006067124152690406-Sep-1013-Sep-103,000Enteric FeverJesingbhai 0006067124152690423-Oct-1026-Oct101,000MMD-General!Jesingbhai 0006067124152690401-Dec-1003-Dec-101,500MMD-General!Jesingbhai 0006067124152690401-Dec-1003-Dec-101,500MMD-General!Jesingbhai

9 9 Government support Advisory being converted into tender clause The enrollment software being standardized Non use of non website data No gap between capture of biometrics and issue Empanelment numbers in tender QMS in five states ( in Pilot districts) FIR to be lodged by state govt against depaneled hospitals

10 10 Thank You

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