THIRUVANANTHAPURAM: Hospitals found to be in violation of the provisions of the MEDISEP health insurance programme for government employees and pensioners will face stringent repercussions, which may include suspension or de-empanelment.
The finance department has meticulously devised a comprehensive Standard Operating Procedure (SOP) to handle complaints against such erring hospitals.
Several grievances have been reported against certain hospitals, including the illicit collection of blank cheques from beneficiaries and the wrongful denial of treatment for specific conditions, thereby breaching the Memorandum of Understanding (MoU) with the government.
According to the SOP, in the event of a complaint or if the insurance company detects suspicious activities within a hospital based on claims or data analysis, the hospital will be closely monitored for 10 days.
Both the insurance company and the nodal cell within the finance department will analyse the data, actively seeking out any patterns, trends, or anomalies that may raise concerns. The hospital will be informed of its placement on the watchlist, along with a clear explanation. Should the insurance company substantiate the involvement of the hospital in wrongful practices, a formal show cause notice will be issued to the hospital, mandating a response within a strict seven-day timeframe.
UNDER THE LENS
During the suspension period, the hospital will not be permitted to accept new admissions, except under certain exemptions. Crucially, hospitals are prohibited from refusing treatment in cases for which pre-authorization has been provided during this period. Subsequent to the investigation, if the complaint is found to be valid, a comprehensive show cause notice will be issued.