| a · 2018. 12. 14. · fraud and a nce. the a, accounta rrence and nti-fraud gu n capability e...
TRANSCRIPT
Fraud Investigation and Medical Audit Manual | a
NATIONAL HEALTH AGENCYDECEMBER 2018
FRAUD INVESTIGATION AND MEDICAL AUDIT MANUALAyushman BharatPradhan Mantri Jan Arogya Yojana (PM-JAY)
Fraud Investigation and Medical Audit Manual | iii
AytethGac
Gprul(Simrisfobe
WHfrafraAm
yushman Bertiary healthhan 40 per
Government occess to hig
Global experirograms notltimate respoSHA). Stronmpact on schsk faced by
or ensuring ee internalize
With this spirion’ble Healtaud and abaud actions udit Manual
manual to stre
Dr. InduChief ExeNational
harat – Prah coverage ocent of Indof India is likh quality hea
ience showst only resultonsibility to g anti-fraudheme financthe SHA, sta
effective imped and perme
it, the Nationth Minister ouse that couand build cfor PM-JAY
engthen the
Bhushan ecutive OfficHealth Agen
Mi
dhan Mantrof Rs. 5,00,0dia’s populakely to have althcare.
s that integrt in financiaeffectively p efforts are
ces and for sate and the
plementationeate all aspe
nal Health Aon 29th Auguld be perpecapacity in S
Y. We sinceremanageme
cer ncy
FORNation
inistry of HeGove
ri Jan Arogy000 to moreation at em
a significan
rity violationsal losses butprevent, dete important safeguardingscheme res
n of PM-JAY ects of mana
Agency has pust 2018 layetrated undeSHAs, NHAely hope thant of anti-fra
REWORnal Health Aealth and Fernment of
ya Yojana (Pe than 10 crompaneled ho
t positive im
s in health it have a muect, and detnot only frog beneficiaryulting from fand it is crit
agement of t
previously dying down ther PM-JAY.
A is proud toat state goveaud activities
RD Agency Family Welfa
India
PM-JAY) enore beneficiospitals. Th
mpact on the
insurance puch greater ter fraud lies
om the persy health butfraud. Hencetical that a “zthe scheme.
eveloped Anhe overall viTo bring un
o share the ernments pas in their res
fare
ndeavors to ary families
his unprecepoor and vu
rograms arer impact on s with the S
spective of rt also to mitie, SHA’s antzero toleran.
nti-Fraud Guision and roniformity andFraud Inves
articipating inpective state
offer secon, accountingdented effoulnerable po
e high. Fraupeople’s he
State Health reducing theigate any reti-fraud efforce” approac
uidelines, reoadmap for cd consistencstigation ann PM-JAY wes.
ndary and g for more ort of the opulation’s
ud in such ealth. The Agencies
e adverse eputational rts are key ch to fraud
eleased by combating cy in anti-d Medical ill use this
Fraud Investigation and Medical Audit Manual | v
Table of ConTenTsfraud and abuse ConTrol under PM-JaY .......................................................................................................... 1
obJeCTive of The Manual ........................................................................................................................................ 2
MiniMuM requireMenTs for audiTs and invesTigaTions ............................................................................... 2
ProCess flow and sTandard forMaTs .............................................................................................................. 3
1. Beneficiary Verification Audits ........................................................................................................................... 3
A. Process flow for audit of cases from CSC or Hospitals ............................................................................. 4
B. Process flow for audit of triggered cases after claims ............................................................................... 5
2. Utilization Audits ................................................................................................................................................. 6
A. Pre-Authorization Stage ................................................................................................................................. 6
B. During Hospitalization stage (live audits, before discharge) ..................................................................... 7
C. Claims Stage (post-facto audits, after discharge) ....................................................................................... 8
3. Mortality Audits.................................................................................................................................................... 9
Process flow for Mortality Audit......................................................................................................................... 9
4. Claims Audits ....................................................................................................................................................... 10
Process Flow ....................................................................................................................................................... 10
Code of ConduCT for sTaff handling field invesTigaTion and MediCal audiT .......................... 11
MonThlY rePorTs and Mis To be subMiTTed To nha ................................................................................ 11
anneXure 1: benefiCiarY audiT forM ........................................................................................................... 13
anneXure 2: MediCal audiT forM ................................................................................................................... 16
anneXure 3: field invesTigaTion forMaT .................................................................................................... 19
anneXure 4: on-siTe invesTigaTion forM .................................................................................................... 22
anneXure 5: MorTaliTY audiT forM ............................................................................................................... 30
anneXure 6: ClaiM audiT forM ........................................................................................................................ 42
anneXure 7: rePorTing forMaT ..................................................................................................................... 44
anneXure 8: handling diffiCulT siTuaTions .............................................................................................. 50
anneXure 9: Trigger PoinTs ............................................................................................................................ 52
Fraud Investigation and Medical Audit Manual | 1
F
Thquantedapr
Frdocoor
PanefIn
Thofrofradelean
Fraud a
he main objuality healthnd effective
ertiary care tata 2011) aractices at e
raud under tocuments orould result rganization.
M-JAY is gonti-fraud culfforts shall
ndependence
he NHA hasf fraudulent obust IT systaud capacitependent on
evel to invesnti-fraud trig
Table 1:
Fraua
Preventio
Detection
Deterrenc
and Ab
ective of PMcare servicecoordination
to the pooreat no cost toeach level.
the PM-JAYr misrepresein unauthoIt includes a
overned basture that pebe based
e, and Reas
s taken sevepractices at tem with a pty building tn the effectistigate fraudgers or by p
Fraud Man
ud managemapproaches
on
n
ce and Reco
buse C
M-JAY is to es in public n between dest of the poo them. The
Y shall mean entation madrized financ
any act that m
ed on a zeroermeates all
on five fosonability.
eral steps toall levels. T
proactive andrainings for iveness and, carry out a
processing te
agement ap
ment s
overies
Control
provide the and private
different stakoor and vulne also expos
and includede by a perscial or othemay constitu
o-tolerance aspects ofounding pri
ensure deteThese included effective fr
State Heald robustnessaudits and neams.
pproaches a
Ben Pro Pre Cla Dat Fie Co Enf Str
l unde
poor and vhospitals. T
keholders winerable (as ses a risk o
e any intentioon or organ
er benefit toute fraud und
approach tof the scheminciples: Tr
ection, prevee developmeraud control th Agenciess of the invenecessary ac
at different
St
neficiary ideovider empae-authorisatiaims manageta analytics
eld and Medintract manaforcement ofingent action
r PM-J
vulnerable poThe success ith a view toidentified byof leakages
onal deceptiization with o herself/himder any app
o any kind ofe’s governa
ransparency
ention, deteent of the Aand detectio
s (SHA). Thestigation action once t
stages of i
tages of im
entification annelment on ement cal Audits
agement f contractuans against th
JAY
opulation of of PM-JAY
o providing qy Socio Ecoin the form
ion, manipulthe knowledmself or so
plicable law i
f fraud and aance. The ay, Accounta
errence and nti-Fraud Guon capabilityhe success nd audit methe suspect
mplementa
mplementatio
nd verificatio
al provisions he offenders
f the countryassumes th
quality secononomic Castm of fraud a
lation of factdge that the ome other pn India.
aims at devepproach to
ability, Resp
spreading auidelines, sey and conduof these ini
echanism atcases are f
ation
on
on
s
y with free he smooth ndary and te Census and abuse
ts and / or deception person or
eloping an anti-fraud
ponsibility,
awareness etting up a cting anti-itiatives is t the SHA flagged by
2 | Fraud Investigation and Medical Audit Manual
O
ThimantraPTrre
M
Thby
Objecti
his Investigmplementingnd recover ansaction/PMJAY impleransaction M
equired to su
Minimu
he Anti-Frauy the SHA u
Audi
Medical aud
Death audit
Hospital aud
Beneficiary hospitalisati
Beneficiary (post dischathrough telephone) Beneficiary discharge –home visit)
Pre-authoris
ive of t
ation manu robust andany fraud re-authorizaementation Managemenubmit month
um Req
ud Guidelinender AB-PM
t Type
dit
t
dit
audit (duringion)
audit arge –
audit (post – through
sation audit
the Ma
al has beend consistent losses unde
ation/Claims adopt standt System anly reports on
quirem
es developedMJAY. The sa
Table 2: R
Sam
5% of to
100% Each emleast twi
g 10% of t
10% of t
5% total
10% of tauthorisaspecialti
anual
n developedanti-fraud in
er PM-JAY submission
dard practicnd for meaninn anti-fraud m
ments f
d by NHA spame are out
Recommend
mple for InsTPA Aud
tal cases ho
mpanelled hoce each yea
total cases h
total cases h
cases hosp
total pre- ations acroses
d by NHA investigation in different and payme
ces, formatsngful reportimeasures w
for Aud
pecifies the mtlined in Tab
ded minimu
surer / it
ospitalised
ospital at ar
hospitalised
hospitalised
pitalised
ss disease
in order to and audit sstages – f
ent. It is crits for data cng and anal
with results a
dits an
minimum sable 2 below:
um sample
Sam
2% direct 2% of audInsurer / T100% Each empa year 5% direct 10% of auInsurer/TP5% direct 10% of auInsurer/TP
2% direct 2% of audInsurer /TP2% of audInsurer / TInsurance 10% of au/ISA (for A
assist SHAsystems to dfrom benefitical that all capture for lysis purposchieved ther
nd Inve
amples for a
for audits
mple for S
audits + its done by t
TPA /ISA
anelled hos
audits + dits done by
PA /ISA audits + dits done by
PA /ISA
audits + its done by tPA /ISA its done by t
TPA /ISA for mode) dits done by
Assurance m
As in develodetect, prevciary identifagencies inintegration e. The SHAreof.
estigat
udits to be c
SHA Audit
the
pital at least
y the
y the
the
the
y the TPA mode)
oping and vent, deter fication to nvolved in with core
As are also
tions
conducted
t twice
Fraud Investigation and Medical Audit Manual | 3
InIn
It al
Thbead
P
ThfofospfohoSt
1.
Claims audiclaims)
Claims audiclaims)
n addition, thnsurance com
is possible lso help fulfi
he Claims Re forwardedddition to be
Proces
he followingor each typeor investigatipecialized eormats applyowever, incltate without
. Beneficia
The proba
Issuan Utiliza Ghost
benefi
Beneficiar
A membeverificatio
it (approved
it (rejected
he model tempany/ISA.
that SHAs ml/meet the a
Review Comd all the seelow mention
ss Flow
g sections pr. As per proion and med
external agey to all agenude additiondiluting the
ary Verificat
able frauds a
nce of e-cardation of servit Utilization iciary
ry audits for
er of entitled n either at a
10% of t
-
ender docum
may like to cbove require
mmittee and erious/repeatned processe
w and S
rovide overvovisions of Adical audit, hncies for cacies carryingnal checks, provisions la
tion Audits
at the level o
d (golden reces under th– Claim su
issuance of
family unde CSC or an
total claims
ments speci
carry out audements or m
Mortality & t fraudulentes.
Standa
view of auditAnti-fraud Guhowever undarrying out g out the tasprovisions, daid down un
of verification
cord) to a nohe scheme bubmitted by
f golden card
er PM-JAY cempanelled
fy minimum
dit and invesmay carry out
Morbidity Ret transaction
ard For
t and investuidelines, SHder certain cinvestigationsk of investidata captureder this man
n of benefici
on-eligible pby someone a provider
d to a non-el
an get a gol hospital
3% of audInsurer /TP10% of au/ISA (for A
100%
m requiremen
stigation of st the same a
eview Commns/reject cla
rmats
tigation procHAs are requcircumstancn and auditgation and ae and analysnual.
ary can inclu
person impersonatwithout act
ligible perso
lden card (e
its done by tPA /ISA for Idits done by
Assurance m
nts for inve
suspect tranadditionally.
mittees set uaims/mortalit
cesses alonguired to recr
ces, SHAs mts. The Stanaudits undersis as requir
ude:
ting to be theual hospital
on
e-card) gene
the Insurance my the TPA
mode)
stigation of
nsactions wh
up at State lty cases fo
g with relevaruit trained m
may utilize sndard procer PMJAY. Sred for their
e beneficiaryization of a
erated after p
mode)
cases by
hich would
level shall r audit in
ant format manpower ervices of
esses and HAs may, particular
y an entitled
process of
4 | Fraud Investigation and Medical Audit Manual
A. Proce
Benefanti-fradischa
ess flow for
ficiary auditsaud triggersarge or post
audit of ca
s will also bes flag the clpayment.
ses from C
e conductedlaim as sus
SC or Hosp
on randomspicious – a
pitals
m basis or poat pre-auth s
ost admissiostage, pre-d
on in cases wdischarge st
where the tage, post
Fraud Investigation and Medical Audit Manual | 5
B. Proce
ess flow for audit of trig
ggered cas
es after claaims
6 | Fraud Investigation and Medical Audit Manual
2.. Utilization
A. Pre-A
At preto SHA‘suspicthe ca2) as be app
n Audits
Authorizatio
e - authorizaA/ Insurer/IScious’ if it m
ase and mayneeded, reqproved denie
Case app
n Stage
tion stage, tSA. Fraud trmeets certaiy choose to quests for aded or referre
F
Pre
roved / denie
the empaneriggers deven pre-definerequest adddditional doced for investi
Pre-Auth req
Fraud Triggers
e-auth team v
Desk Audit c
Addition
Do
ed
led health celoped by Ned criteria/triditional docucuments. Aftigation.
quest received
s flag pre-aut
validates susp
confirms claim
nal document
ocuments Rev
care providerNHA/SHA woiggers. The
uments or coter reviewing
d by SHA/IC/I
th as ‘suspicio
picion – Desk
m as suspicio
ts requested
viewed
r sends pre-ould flag thepre-auth ap
onduct a meg the docum
ISA
ous’
Audit
ous
Case s
Send foInvest
-authorizatioe pre-auth repproval team
edical audit (ment, case m
suspicious
or further tigations
on request equest as m reviews (Annexure may either
Fraud Investigation and Medical Audit Manual | 7
B. DurinDuringsent fosent fomerits
g Hospitalizg hospitalizaor field inveor action/dens as in norma
zation stageation stage, stigation (Annial of pre-aal course.
Case
F
System getriggere
e (live auditsystem triggnnexure 3). uthorization
No
Case processe
meri
e sent for fiel
Fraud confirmdischa
enerated d case
ts, before dgered casesIf fraud is cand if confi
is ed on ts
Case dPre
d investigatio
med before rge
discharge) s, or the casconfirmed bermed as non
directed by the-auth team
on
es directed efore the disn-fraud, the
Yes
he
by pre-authscharge, thecase is proc
Casea
team are en case is cessed on
e sent for action
8 | Fraud Investigation and Medical Audit Manual
Sre
findm
offif
de
C. ClaimIn castriggerTheseensurelevel snaturealso bReviewinvest
Send eports and
dings to edical icer for final
ecision
ms Stage (pose of post-drs will highli
e cases are fe that any ascrutiny, thee of fraud trigbe triggered w Committeigation, then
InveConfi
ost-facto auischarge or ight certain first revieweapparent faln the case wgger and thebased on re
ee in the nn its report a
Fie
estigation irms Fraud
udits, after dat the timecases as “s
ed by the Insse positiveswill be sent e evidence neview by Stanormal cournd findings a
Tri
Fact verifi
M
Frau
Case s
Yes
eld Investigat
NM
discharge)e of claim adsuspect” whsurance Coms are filteredfor field inveneeded for vate Claims Rse of their are shared b
iggered cases
ication by des
Fraud Suspect
edical Audit
ud Confirmed
sent for actio
Yes
tion or on-site
Needs further Medical Audit
djudication/ hich would nmpany/ ISA fd out. If theestigation orverification (Review Comfunctions.
by Medical O
s
sk audit
d
n
Ye
e investigatio
tIn
payment ofneed to be for prima-fac case remar medical au(refer annexmmittee andIf fraud is
Officer for th
Casmed
Ccl
No
Ye
es
on
nvestigation case as non
f the claim, investigatedcie/ fact veri
ains suspectudit dependix 3,4). The c Mortality & confirmed e final decis
e sent for dical audit
Case osed
es
confirms n fraud
the fraud d/ audited. ification to t post first ing on the
cases may Morbidity
after field sion.
Case closed
Fraud Investigation and Medical Audit Manual | 9
3.
As regdesk acommclaim docum
In boInvestmatter
. Mortality
As per Anbe requirereviewed in case oMorbidity
Process
Evea b
Eacrevclai
Stadea
Fin
gards casesaudit or field
municate his may be sen
mentation wh
th cases, ttigator, on-sr.
Audits
nti-Fraud Gued to provideand verified
of death dueCommittee f
flow for Mo
ery death ocrief death such network iew/examineims submiss
ate Mortality ath cases al decision w
s triggered/md audit depefinal finding
nt for field ihich may hav
the Medicalite investiga
idelines, 100e all the rele by the audi
e to negligefor final revie
ortality Aud
ccurring in thummary
hospital to e the causesion
and Morbid
would be tak
marked for mending on thgs to the Mnvestigationve been coll
l officer wilation team a
0% mortalityevant informait team to id
ence. All casew and deci
dit
he network h
constitute e of death a
dity Committ
ken by State
medical audhe facts to edical office
n followed bected during
ll review thand Medical
y claims wouation as speentify the reses of Mortision.
hospital sho
a Mortality nd the repo
tee to scree
e Mortality an
dit, the Medbe verified t
er for his finby a medicag the first sta
he observat Auditor wh
uld be referreecified in Aneal cause of tality must b
uld be intim
Audit commort shall be
en and cond
nd Morbidity
dical Auditorto confirm t
nal decisionl audit teamage.
tions and fhile taking a
ed for auditsnexure 5 andeath and t
be put up to
ated to SHA
mittee and submitted to
duct detailed
y Committee
r may also cthe suspicio. In some c
m to review
findings of final decisio
s. The hospitnd the sametake necesso State Mor
A within 48 h
this commio SHA at th
d mortality a
.
conduct a n and will
cases, the additional
the Field on on the
tals would e would be ary action rtality and
hours with
ittee shall he time of
audit of all
10 | Fraud Investigation and Medical Audit Manual
4.
. Claims A
There maby the Insrandomly mentioned
Claim ISA / S
Randoeach p
Process Trigge Medic
submi SHA t
require
Audits
y be some fsurance com
selected cad as Annexu
Review comSHA and apomly review provider eac
Flow ered cases ocal doctor of ssion and shakes a final ed.
fraud cases mpany/TPA/ Iases or triggure 6.
mmittee shalpealed by th/ audit at lea
ch quarter.
or randomly sthe audit teahares reportdecision ba
which may ISA/ SHA. Tgered cases
ll Review 10he provider;ast 2 percen
selected appam validatest with findingsed on the r
initially go uTo identify sus is done o
0 percent cl
nt of the pre-
proved/paid s the documegs. report finding
undetected auch claims, ion a periodi
aims that ar
-authorizatio
cases are aents submitt
gs and takes
and incorrectit becomes ic basis. Th
re rejected b
ons and 3 pe
assigned to tted by the ho
s disciplinary
tly approvedimportant th
he reporting
by the Insure
ercent of the
the audit teaospitals duri
y action whe
d and paid at audit of format is
er / TPA /
claims of
am ing claims
erever
Fraud Investigation and Medical Audit Manual | 11
CIn
M
Thtotathacm
Code onvestig
To main To carry
any man To main
and aud To alwa
and prod To alwa Not to g
agency
Monthl
he SHAs areo control frauaken againsthe progress ction as nee
monthly repor
of Condgationntain highesty out investinner whatsontain confidedit and submays carry auduce the sam
ays maintain give impressworking for
y Repo
e required toud, data anat fraudulent of the state
ed be. Refert format to b
duct fo and M
t standards ogation/audit
oever entiality of h
mit the same uthorization/me to hospitdignity of pa
sion of extraSHA under
orts an
o submit moalysis, cases
parties, notes, draw co
er to Annexube collected
or StafMedica
of professionwork withou
health data/to competenpermission tal/beneficiaatient and soaneous authPM-JAY
nd MIS
nthly report s investigatedices, issued
omparative aure 7 for theat district le
ff handal Audit
nal conduct ut disrupting
information nt authority from compery as the caocial norms hority of any
S to be
by 7th of evd and audite
d, recoveriesanalysis, proe format of
evel for their
dling Ft and integrity
g or interferi
collected d
etent authorse may be during bene
y kind while
Subm
very month toed and the rs made etc. ovide furthethe report. own referen
ield
y in all situatng in ‘treatm
uring the co
rity to condu
eficiary intervacting on b
mitted t
o NHA listingresults there
This would er support a
It is suggence and deta
tions ment of bene
ourse of inv
uct investiga
views behalf of SH
to NHA
g the measueof and punit
enable NHAnd feedbacsted to the
ailed analysi
eficiary’ in
vestigation
ation/audit
HA or any
A
ures taken tive action A to track k, to take SHA that s.
B
Ben
PRA
Anefic
AYDHAN M
nneciary
YUSHMAMANTRI
exury AuAN BHAJAN AR
re 1:udit ARAT – ROGYA Y
: For
YOJANA
rm A
14 | Fraud Investigation and Medical Audit Manual
S
A. Patien
1. PM2. Na3. Fa4. Ad
Dis5. Co6. Me
S. No.
1.
2.
3.
4.
5.
6.
B. Gener
1. W
2. If h
3. Ha
4. In
5. W
6. W
7. W
nt Informati
M-JAY FAMIame: ather’s or Huddress: strict: ontact No. embers regis
Name
ral Informat
here was the
hospital, was
as s/he avail
which hospi
hat symptom
hen did s/he
hen did s/he
on
ILY ID: ____
usband’s nam
stered:
P
tion
e E card ma
s the benefic
led services
ital did s/he
ms were the
e get admitte
e get dischar
__________
me:
State:
M-JAY ID number
ade?
ciary charge
under PM-J
utilize the se
patient exhi
ed?
rged?
Annexure 1
________
ed any mone
JAY? If yes -
ervices?
ibiting when
1
P
Gender
ey for the E c
-proceed fur
he/she visit
Pin Code:
Ag
card? If yes,
rther
ted the hosp
ge Re
, how much?
pital?
elationship
?
Fraud Investigation and Medical Audit Manual | 15
8. Fo
9. W
10. W
11. If aye (4
C. Match
D. Any o
E. Recom
Name an
or how many
as s/he prov
hat was the
any surgery,
es, take phot
-11: match
h the photo
other remark
mmendatio
nd Signatur
y days was s
vided free fo
treatment g
, is there a stograph of th
the informa
of the bene
k or observ
n of the Au
re of the Au
s/he hospital
od?
iven?
scar on the bhe same)
ation provide
eficiary bein
vation:
ditor:
ditor with D
Annexure 1
lized?
body, which
d by the ben
ng interview
Date:
1
could help in
neficiary with
wed with the
n verification
h the one re
e one subm
n of the surg
corded in th
mitted in TM
gery. (If
e TMS)
MS
Annexure 2:Medical Audit Form
aYushMan bharaT – Pradhan ManTri Jan arogYa YoJana
Fraud Investigation and Medical Audit Manual | 17
Options for answer selection
Remarks
S. No. Criteria1 Pertaining to Clinical Information (Patient history and evidence of
physical examination is evident)a. Is the chief complaint recorded? Pl look for package specific complaints Yes/ No
b. Is History of present illness (HOPI) mentioned? Should have Onset, duration and progress of relevant symptoms/ signs
Yes/ No
c. Are relevant personal history of beneficiary noted (positive or negative)? Viz, abuse of tobacco/ alcohol/ intoxicating substances consumption? (the next Q get enabled if answer to this Q is YES)
Yes/ No
d. Is the above positive history relevant to having caused the package diagnosis?
Yes/ No
e. Does this above history (whether captured or not) makes the package NOT applicable as per exclusion policy?
Yes/ No
f. Is a report on relevant physical examination available? Pl look for package specific findings
Yes/ No
g. Is general examination and other systems (CVS, CNS, AS, RS) done and findings reported? Pl look for package specific data
Yes/ No
2 Progress notes from admission to dischargea. Are admission notes and detailed findings at admission notes available? Yes/ No
b. Are daily recorded progress reports available? Pl look for package specific sequential information, which should have been captured.
Yes/ No
c. Is each progress report signed and dated? Yes/ Nod. Are reports of patient’s progress filed chronologically? Yes/ No
e. Are Specific instructions to discharge the patient and line of treatment after discharge captured in ICP's?
Yes/ No
f. Is a Discharge summary available? Yes/ Nog. Does the discharge summary capture all details of presenting features,
investigations, line of treatment given during stay line of treatment advised at discharge and (Select <No> if investigations and all treatment details, missing as follow up will be not be rational)
Yes/ No
h. Are instructions to follow up explicitly given? Yes/ No3 Pathology/ laboratory/ Radiology reports Scrutiny (only one of the 2
sets a-d or e-f have to be answered ) a. If it is a Medical / emergency surgery Package, Are pathology/
laboratory reports available Yes/ NA
b. Are reports relevant to package, the diagnosis and treatment given? Package specific list
Yes/ No
c. If it is a Medical / emergency surgery package, Are radiology reports available?
Yes/ NA
d. Are reports relevant to package, the diagnosis and treatment given? Package specific list
Yes/ No
e. If it is a planned surgery package, Are justifying lab/ radiology / Frozen section/ FNAC/ biopsy reports available?
Yes/ NA
f. Are reports relevant to package diagnosis, the diagnosis and treatment given? Package specific list
Yes/ No
4 Is an operation report available? (Only for surgical Packages) Yes/ No
This Surgery Is more likely to be Planned surgery/ emergency surgery/ could be either emergency or planned surgery.
Is Pre-op Profile Available (Relevant to Package, Age & Co-morbidities)
Yes/ No
Modified Medial Audit Qs
18 | Fraud Investigation and Medical Audit Manual
4A. Planned surgery- Yes/ NAa. Does the report include Pre and post-operative diagnosis (Both should be
same)?Yes/ No
b. Is the correct package blocked? Yes/ Noc. Are the justifications of arriving at the diagnosis rational? Package
Specific list Yes/ No
d. Is the date and time of procedure mentioned? Yes/ Noe. Is the surgeon who has operated same as the name given while blocking
the package?Yes/ No
f. Is the surgeon’s signature available on records? Yes/ No4B. Emergency surgery Yes/ NAg. Does the report include pre-operative diagnosis? Yes/ Noh. Does the report include post-operative diagnosis? Yes/ Noi. Are the above two similar? (Need not be exactly same) Yes/ Noj. Was the decision to operate rational w.r.t clinical features? Yes/ Nok. Are the justifications of arriving at the diagnosis specified? Yes/ Nol. Is the date and time of procedure mentioned? Yes/ No
m. Is the surgeon who has operated same as the name given while blocking the package?
Yes/ No
n. Is the surgeon’s signature available on records? Yes/ No5 Documentation scrutiny
a. Do all entries in medical records contain signatures? Yes/ Nob. Are all entries dated? Yes/ Noc. Are times of treatment noted? Yes/ Nod. Are signed consents for treatment available? Yes/ Noe. Is patient identification recorded on all pages? Yes/ Nof. Are all nursing notes signed and dated? Yes/ No
6 Does the claim fall under any clause of Schedule 2 - Exclusions to policy Yes/ No
Auditor's Conclusion Red/ Amber/ GreenSpace for adding observations basis which this conclusion is arrived at
Annexure 3:Field Investigation Format
aYushMan bharaT – Pradhan ManTri Jan arogYa YoJana
20 | Fraud Investigation and Medical Audit Manual
Reason for field validation Routine claims review medical audit request
Name of Patient Gender RelationPM-JAY card no. or State Specific scheme No. Address
Name of Hospital - Address of Hospital -
Hospital ID (if available)
Hospital Existence Yes NoResponse from Hospital Co-operative Non Co-operative IndifferentIs Hospital Registered DGHS Yes No Reg. No. No of BedsNo of OTPathology/ Diagnostics Inhouse Out sourced Not Available Type of Hopsital Public PrivateName of Treating DoctorSpecialityDr Registration NumberContact Number of Treating DoctorDate and time of Hospital Admission as per hospital file Date and time of Hospital Discharge as per hospital file Type of Treatment Surgical ConservativeIf MLC/FIR, not available then specify the reasonsDiagnosis:
Yes No
Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No
Yes NoYes No
D. Patient profile Patient Photograph collected with ID card (upload)Patient Id's proof Collected (upload)
Was he/she operated upon, if yes, is there a scar on the body, which could help in verification of the surgery.(If yes, take photograph of the same)
C. Documents Review: Observations noticed for each parameter need to be entered in terms of completeness, errors, overwriting or any discrepancies noticed
Any other remark or observation:
Is IPD CollectedIf yes, please upload If no specify the reason Indoor Register Entry Verified (upload)
Has any money been charged so far? If yes, how much?
Deatiled progress notes reflecting evaluation of each visit, reason for visit is documented as relevant
E. Patient/Attendent interview in the hospital
Annexure 3 - Field Investigation Format
B. Facility inspection: Need to match against the details submitted at the time of empanelment and claim submission
A. Patient/Claims Details
What symptoms were the patient exhibiting when he/she visited the hospital?
All Medical Histroy of patient documented (upload)Pateint clinical information is documented (upload)Is there any previous hospitalization of same patient at the same hospital Past history details documentedComplete Medication list on chart and nursing chart (upload)Findings and follow ups are documented (upload)
Hospital Lab Register Verified (upload)Treating Doctor Certificate Verified (upload)
Any other remark or observation:
When did the patient got admitted? Is the patient admitted since then?Was the patient informed about the name and value of the package which was blocked by the hospitalWhat diagnostic tests (if any) were performed on the patient?
Any other remark or observation:
Fraud Investigation and Medical Audit Manual | 21
Comment of Investigator
Final Opinion of the Investigator GenuineFraudAbuse
Name of Investigator
Signature of Investigator
Investigation Date & Time
District/State official Siganature
Past History Details (Non Mandatory)
Name of DiseaseDuration prior to
getting admitted Only Yes/NO
High Blood pressure Yes NoDiabetes Yes NoAsthma Yes NoCancer Yes NoIHD/MI Yes NoTobacco Yes NoAlcohol Yes NoOthers
Any other remark or observation:
Any other remark or observation:
F. Home Visit: Patient/Attendent interview after discharge
Was post-hospitalization medication provided to the patient? Was any money asked by the hospital at any point of time. If yes, then how much and for what purpose?Was patient or the attendant asked to purchase any the medicine or carry on any of the diagnostic test attheir own cost? Does the patient have any receipt for the same? (If yes, take photograph of the same)
Was the patient given a discharge summary? Does the patient still possess that discharge summary? If yes physically verify the same
Has s/he availed services under PM-JAY? If yes -proceed further. In which hospital did s/he utilize the services? What symptoms were the patient exhibiting when he/she visited the hospital?
What was the treatment given? If any surgery, is there a scar on the body, which could help in verification of the surgery. (If yes, take photograph of the same)
When did s/he get admitted? When did s/he get discharged?
Was the patient informed about the name and value of the package which was blocked by the hospital
For how many days was s/he hospitalized?Was s/he provided free food and travel allowance?
On
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Fraud Investigation and Medical Audit Manual | 23
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umber of pe
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24 | Fraud Investigation and Medical Audit Manual
TRINC
Utri
2. Onsi
RIGGERS FNVESTIGATlaims patter
1. High incare p(<24ho
2. Repeahigher(>Rs.
3. Length> 15 d
4. Numbdisprostreng
5. Inter-dcompadistric
6. Blockihospitfor
7. ShowiICU th
8. Blockipacka
nethical mediggers:
1. ICU adthan 7
2. Diseasrelatedpatien
3. PossibOutpaInpatie
4. Hysterfor pat
5. CatarasurgerAge
6. Claimsdifferedistric
te or field in
FOR ONSITETION n triggers: Encidence of
procedures ours) ated blockingr-priced pack15,000) h of stay at hdays er of claims
oportionate wgth of hospitadistrict claimared to with-t claims ng of cases
tal is not equ
ing admissiohough not eqng of multipges/procedu
dical practic
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nt ble Convers
atient cases tent cases rectomy perftients <40yrsact related ries for <45 y
s pattern of ent from that t
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OURCE OFDATA Claims detailsubmitted by nsurance
Companies /tate Health
Agency / HA server etails
Claims detailsubmitted by nsurance
Companies /tate Health
Agency / HA server etails & omplaints orrievances gainst the ospital.
F TOOLS FINVESTI
s *Checklisinspectiohospital, of inpatierecords &of staff *Questiointerviewbeneficia
s
r
*Checklisinspectiohospital, of inpatierecords, of operatevaluatioavailabili*Questiointerviewbeneficia*Clinical protocol/
FOR IGATION st for -facilityon at
evaluation ent case & availability
onnaire for w of ary
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/pathways
PROCESINVESTI
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Based ontriggers hpossible scheme gidentifiedOn site vmedical aand invesavailabilitinfrastrucdone. Case recbe lookedInterviewregardingany dematreatmenDetailed investigafor empadisciplinafurther ac
y Based ontriggers acomplainhospitalsdeviationguidelinelisted. On site vmedical a– case relooked fosurgeriesclinical pguidelineinfrastruchospital idone. Detailed investigafor empadisciplinafurther ac
SS OF ON-SGATION n the predetehospitals witdeviations fguidelines a
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cords of patied for treatme
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n the predeteand nts/grievances with possibns from schees are identif
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es. Facility, cture and recinspection w
report of theation will be sanelment andary committection.
SITE
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ermined
es ble eme fied and
tals by members tients are
es & using ways
cords of will be
e submitted d ee for
Fraud Investigation and Medical Audit Manual | 25
Frraudulent ac1. Odd h2. Unusu
transa3. Claims
differedistric
ctivities trigghour transactual increase actions s pattern of
ent from that t
ers tions in
hospital of
CsuInCSANdecogragho
Claims detailsubmitted by nsurance
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s
r
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elines.
fBased ontriggers acomplainhospitalsdeviationguidelinelisted. On site vmedical aCompletescheme fdischargeof buildinreviewedchecklistscheme gany fraudPost discwill be intdetectingany fraudDetailed investigafor empadisciplinaSHA for f
n the predeteand nts/grievances with possibns from schees are identif
visit to hospitaudit team me process offrom registrae (including
ng, accountsd and evaluas, clinical prguidelines todulent activitcharged benterviewed fo
g quality of sdulent activitreport of the
ation will be sanelment andary committefurther legal
ermined
es ble eme fied and
tals by members. f the ation to records
s etc.) is ated using rotocol & o detect ties. eficiaries
or service & ties. e submitted d ee at action.
26 | Fraud Investigation and Medical Audit Manual
3. Chec
QUESIs therempanIs therabout
Is ther
Is therIs therof the
If yes,
Is any
If yes,
QUES
At leas
At leas
At leas
There experiward o
There
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All trea
cklist Temp
STION re any signbonelled in schre any signagthe scheme
re a scheme
re a staff/ Arore any schemvisit?
how many s
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how many p
CHEC
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st 1 medical
st 1 nurse (R
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oard outsideheme? ge inside the?
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CKLIST FOR
officer (RMP
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re blocked?
R AVAILAB
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r is present (
ppropriately qle for the ma
specialists in
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vestigation
ION/ HELP D
howing that it
f giving infor
al?
e help desk?he hospital a
mitted
eing admitte
ILITY OF ST
at all times
es
(staff) at all t
qualified andanagement o
an emergen
MBBS docto
e hospital
ns
DESK CHEC
t is
rmation
? at the time
ed?
TAFF AT TH
times.
d/or of each
ncy
or on 24x7
CKLIST
Response
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
HE HOSPITA
Response
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
e REM
AL
e REM
MARKS
MARKS
QUESDocumanaesInformby the Detailsrespiraand leOT NOconce
Patien
QUES
OT Ste
Adequis provA heigavailab
The op- Anae- Laryn- Endo– Airw- Nasa- Sucti– Oxyg- Drug- MoniapplicaDefibr
Runnin
Hot wa
Proced- Inform- Pre-o- Post-
CHEC
STION mented pre-athesiologist
med consent Anaesthetis
s of Recordeatory rate, Bvel of anaes
OTES- Detairned special
nt’s post ana
CH
STION
erilization fa
uate lights (gvided in eachght adjustablble. peration theaesthetic macngoscopes (otracheal tub
ways al tubes ion apparatugen s for emergetoring equipable), pulse illator
ng tap water
ater supply i
dures are avmed patient operative as-operative ca
CKLIST FOR
anaesthesia
for administst ed monitorinP, O2 satura
sthesia ils of procedlity
esthesia sta
HECKLIST F
cilities funct
general levelh OT e OT Table,
atre is equipchine and ve(Adult / Paedbes/laryngea
us and conne
ency situatiopment includ
oximeter an
r supply in O
n OT
vailable and consent sessment are
R EVALUAT
assessmen
tration of Ana
g of heart raation, airway
ure done by
atus is monit
FOR OPERA
ional.
illumination
shadow les
pped for its pntilator diatric) al masks
ectors
ons ing ECG, ET
nd blood pres
OT
up to date fo
TION OF SU
nt by a qualif
aesthesia is
ate, cardiac ry security, an
y respective
ored and do
ATION THE
n) and Air co
ss Operating
purpose and
TCO2 (wherssure, cardia
or:
URGICAL PR
fied
s obtained
rhythm, nd potency
surgeon of
ocumented.
EATRE/DEPA
onditioning
g light is
includes:
re ac monitor,
ROCEDURE
Response
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
ARTMENT
Response
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
ES
e REM
e REM
MARKS
MARKS
Fraud Investigation and Medical Audit Manual | 27
QUESDocumanaesInformby the Detailsrespiraand leOT NOconce
Patien
QUES
OT Ste
Adequis provA heigavailab
The op- Anae- Laryn- Endo– Airw- Nasa- Sucti– Oxyg- Drug- MoniapplicaDefibr
Runnin
Hot wa
Proced- Inform- Pre-o- Post-
CHEC
STION mented pre-athesiologist
med consent Anaesthetis
s of Recordeatory rate, Bvel of anaes
OTES- Detairned special
nt’s post ana
CH
STION
erilization fa
uate lights (gvided in eachght adjustablble. peration theaesthetic macngoscopes (otracheal tub
ways al tubes ion apparatugen s for emergetoring equipable), pulse illator
ng tap water
ater supply i
dures are avmed patient operative as-operative ca
CKLIST FOR
anaesthesia
for administst ed monitorinP, O2 satura
sthesia ils of procedlity
esthesia sta
HECKLIST F
cilities funct
general levelh OT e OT Table,
atre is equipchine and ve(Adult / Paedbes/laryngea
us and conne
ency situatiopment includ
oximeter an
r supply in O
n OT
vailable and consent sessment are
R EVALUAT
assessmen
tration of Ana
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ure done by
atus is monit
FOR OPERA
ional.
illumination
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pped for its pntilator diatric) al masks
ectors
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nd blood pres
OT
up to date fo
TION OF SU
nt by a qualif
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ATION THE
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ss Operating
purpose and
TCO2 (wherssure, cardia
or:
URGICAL PR
fied
s obtained
rhythm, nd potency
surgeon of
ocumented.
EATRE/DEPA
onditioning
g light is
includes:
re ac monitor,
ROCEDURE
Response
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
ARTMENT
Response
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
ES
e REM
e REM
MARKS
MARKS
28 | Fraud Investigation and Medical Audit Manual
Emergequipm
Steri la(mand
Functiequipm
The Odispos
Regula
Carbo(docum
Reguladocum
QUESICU-deequipmcrash oxygenAnaesNursin What iStandbpower
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QUESAge
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E Card
Date o
gency powerment’s (embabels are us
datory for oponal annual
ment’s. T complex is
sal zones (m
ar document
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mented)
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STION esignated aiment for the cart, defibriln facility
sthesiologist-ng/Diploma h
is the Nurseby Generatosupply.
es and proceive and highon rate in IC
ESTIONNAI
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er
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patient have
d number
of Admission
r supply conedded UPS)
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KLIST FOR
r conditioneconstant molator, ventila
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edures for adh dependencCU, re-admis
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n in the hosp
nection is av) taining the qecialty) ce contract fo
to sterile, clehysically)
ving of instru
our Room af
erilization (ca
EVALUATI
d space withonitoring for ators, suction
Nursing Stafs of ICU exp
tio? stalled in IC
dmission, discy unit, docussion rate, re
PATIENTS (B
hold
h him/ her?
pital
vailable for a
quality of aut
or all major
ean, protectiv
uments & line
fter every pro
arried out an
ION OF INT
h Standard Ivitals, emer
n pumps, be
ff: B Sc erience
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all OT
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nd
ENSIVE CA
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mergency
eria for its ntrol of rates.
ARY) ADMIT
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
ARE UNIT (IC
Response
Yes / No
Yes / No
Yes / No
Yes / No
TTED IN THE
Response________ Y
Yes / No
CU)
e REM
E HOSPITA
e REMYears
MARKS
L
MARKS
Fraud Investigation and Medical Audit Manual | 29
Since
Was fi
Do youthe sc
Was th
Were ahospita
How wprovid
Were y
If yes, for trea
Will yothe sa
If no, w
What a
Underta
This is to
best of
hospital/i
in case t
hospital s
Name/Si
how many d
ngerprint veu know abouheme?
he patient prall patient real for treatm
would you raed at the ho
you/your famtotal amoun
atment ou recommeme hospital?
why?
are the patie
king by Hos
o certify that
my/our kn
institution. I/
the informat
stands to for
gnature/Dat
days patient
erification dout any provis
rovided with elated querieent under th
te your satisospital?
mily forced tont medical ex
nd your rela?
ent’s sugges
spital
t the informa
nowledge a
/ We had no
tion provide
rfeit its claim
e with Seal
is admitted?
ne through asion of trans
food duringes answeredhe scheme?
sfaction abou
o give monexpenditure p
atives/friends
stions for imp
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t suppresse
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ms.
of the Autho
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s to take trea
proving the s
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hospital? r visit to
ment
ent? ent/family
atment from
scheme?
s about hosp
umentation
mation or fac
rect and bas
on.
Yes / No
Yes / No
Yes / No
Yes / No
Excellent-1 Very good-2Good-3 Average-4 Poor-5
Yes / No
Yes / No
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pital, Distric
and proce
ct. Further, I/
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Fraud Investigation and Medical Audit Manual | 31
Annexu
Source: w
Section 4.
1. Deat H H P P N A S L C C E D D
2. Prog
A H W W
g W W
M P W W A
ure 5 – Mor
www.sast.gov.i
1. and 4.2. is t
h SummaryHospital NamHospital ID Patient ID (ePatient CharName Age Sex Length of AdClinical DiagClinical diagEmergency Date of AdmDate of Deat
ress of the
Abnormal InHematologyWhat was thWere there agiving good Were there iWere there aMedical ClinPlease give Were all stanWhat accordAny other re
rtality Audi
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to be filled by
y (A brief nome
e-card numbracteristics
dmission in dgnosis (es) onosis(es) onor Elective
mission: th:
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he treatment any clinical equality care?identifiable cany of the cl
nical Errors, Nfurther detandard protocding to the tremarks
it
the hospitals
ote)
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ring hospita
s: try, Radiologprovided?
errors, omiss? clinical risks/inical risks/iNursing Clinils below cols followedreating docto
s and sent at th
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alization
gy, Microbio
sions, proce
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d? or is the cau
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ess problems
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se of death
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and contribu
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uting factors
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ess of
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s?
32 | Fraud Investigation and Medical Audit Manual
Mortality
The comdepartme
Aims an
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Areas to
Area of C
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The com
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mprises of ing manage
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ortion of patalthcare proor from actsfocus shoul
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clinician be
unintended iiently serioulity of the pa
‘DEATH AU
n
diotherapy/ C
r
constituted ng doctors a
tality audits
tients who docesses incls of commisld be on the
lieves that a
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UDIT REPO
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s
ied becauseuding acts ssion (affirme systems a
areas of care
ed by medic prolonged time of disc
RT’ as men
py/ Others (
hospital thadepartments
e of 'problemof omission
mative actionnd processe
e SHOULD h
cal managehospitalizaticharge, or w
ntioned belo
(specify)
at represents.
ms in care', dn (inactions)ns) such ases of care a
have been b
ement ratheon or to tem
which contrib
ow :
t the key
defined as , such as
s incorrect and not on
better.
r than by mporary or butes to or
Fraud Investigation and Medical Audit Manual | 33
Section
Please padmissio
Section
1. Wer- Ye
2. Was3. Wer
Operatio
Pre-anes
Decision
Choice o
Timing o
Intra-ope
Problems
Grade / e
Grade / e
Post-ope
4. WasYes/
5. If noYes/
B - Case S
provide a sumon, chronolog
C: Case As
re there any s/No
s surgery pere there any
n/procedure
sthetic check
n to operate
of operation
f operation (
erative proce
s in function
experience o
experience o
erative period
s this patient/No
o, should this/ No
ummary
mmary of thgy of events
ssessment
areas of CO
rformed? Yeareas of Co
e was perform
kup/fitness fo
(too late, too
ess
ing of OT
of surgeon d
of surgeon o
d
t treated in a
s patient hav
e Case in th up to death
ONCERN or
es/ No oncern, or Ad
med, or trea
or surgery/tr
o soon, wron
deciding
operating
a critical care
ve been prov
he form of nh of the patie
ADVERSE
dverse Even
tment provid
reatment
ng time of da
e unit (ICU o
vided critical
narrative – inent –
EVENTS in
nts in any of
ded?
ay)
or HDU) duri
l care in ICU
ncluding com
n the manage
the following
Yes N
ing this adm
U/HDU?
mplaints at th
ement of thi
g?
No NA
ission?
he time of
s patient?
34 | Fraud Investigation and Medical Audit Manual
Opinion
-
If there a
Describe
Note any
Note if th
Made no
May have
Caused d
Was the know
Section
Hospital
Primary c
ICD code
Seconda
ICD Cod
Antecede
ICD code
FINAL R
1. _____2.______3.______
of the Aud
Minimal/ M
any areas of
e the significa
y areas of co
hese areas c
difference t
e contributed
death of pat
death preve
D: Record o
l mortality a
cause of dea
e: ________
ary cause of
e: ________
ent cause of
e: ________
RECOMMEN
_______________________________
it committe
Mild/ Modera
CONCERN
ant event/s d
oncern or Ad
caused any o
to outcome _
d to death__
ient who wo
entable? (i) D
of cause of
audit comm
ath: _______
___________
death: ____
__________
f death: ____
___________
NDATIONS (
________________________________
ee regarding
ate/ Severe
or ADVERS
during the co
dverse Event
of the follow
__________
__________
uld otherwis
Definitely (ii
death
mittee review
__________
__________
___________
___________
__________
__________
if any) OF T
_______________________________
g overall ris
SE EVENTS
ourse of trea
t
ing:
___________
___________
se be expect
i)Probably (
w findings:
__________
__________
__________
__________
__________
__________
THE MORTA
_______________________________
sk of death
S in the mana
atment in the
___________
__________
ted to surviv
(iii) Probably
___________
___________
__________
__________
___________
___________
ALITY AUDI
________________________________
agement of t
e hospital:
__________
__________
ve_________
y not (iv) De
__________
__________
___________
___________
__________
__________
IT COMMITT
______________________________
this patient:
___________
_________
_________
finitely not (
_________
________
_______
_____
_________
________
TEE
________ ________ ________
______
(v) Don’t
Fraud Investigation and Medical Audit Manual | 35
Attestati
N
1
2
3
Date:
ion by the M
Name
Mortality Auudit Commit
Designatio
ttee membe
on
ers:
Signat
ture
36 | Fraud Investigation and Medical Audit Manual
First Line Assessment Form on Hospital Mortality Audit Report
Case Note Review
A case note review is a peer assessment of the death of a patient. It should be carried out in a spirit of sympathetic enquiry and provide sufficient detail for a clear view of events. Points should be made in a detached manner and any opinions expressed should be objective and reasonable.
Aim
The aim is to ascertain the proportion of patients who died because of 'problems in care', defined as patient harm resulting from healthcare processes including acts of omission (inactions), such as failure to diagnose and treat, or from acts of commission (affirmative actions) such as incorrect treatment or management.
Criteria for Ranking
An area of CONSIDERATION is where the clinician believes areas of care COULD have been IMPROVED or DIFFERENT, but recognises that it may be an area of debate.
An area of CONCERN is where the clinician believes that areas of care SHOULD have been better.
An ADVERSE EVENT is an unintended injury caused by medical management rather than by disease process, which is sufficiently serious to lead to prolonged hospitalisation or to temporary or permanent impairment or disability of the patient at the time of discharge, or which contributes to or causes death
Fraud Investigation and Medical Audit Manual | 37
Section A: General Information
Patient details:
Name:
Age: Sex: Pre-auth No.
DOA: DOD:
Diagnosis:
Reviewing Doctor:
Please provide a summary of the Case in the form of narrative
___________________________________________________________
Section B: Case Note Assessment
Were there any areas of CONSIDERATION, of CONCERN or ADVERSE EVENTS in the management of this patient?
Yes
No
1 Describe the most significant event:
Was surgery performed? Yes No
Were there any Areas of Consideration, of Concern, or Adverse Events in any of the following areas if an operation was performed? Discussion points Yes No N/A Pre anaesthetic check up/fitness for surgery Decision to operate Choice of operation Timing of operation (too late, too soon, wrong time of day) Intra-operative process Problems in functioning of OT Grade / experience of surgeon deciding Grade / experience of surgeon operating Post operative period
38 | Fraud Investigation and Medical Audit Manual
If yes above, provide details of
Area of:
Consideration
Concern
Adverse Event
Which:
Made no difference to outcome
May have contributed to death
Caused death of patient who would otherwise be expected to survive
Was it preventable?
Definitely
Probably
Probably not
Definitely not
Don’t know
Please provide evidence to support your statements given above by referring to specific points relating to any investigation reports or progress of the patient, treatment provided etc., which substantiate your observations
______________________________________________________________________________
2 Describe the second most significant event:
______________________________________________________________________________
Area of:
Consideration Concern
Adverse Event
Which:
Fraud Investigation and Medical Audit Manual | 39
Made no difference to outcome
May have contributed to death
Caused death of patient who would otherwise be expected to survive
Was it preventable?
Definitely
Probably
Probably not
Definitely not
Don’t know
Please provide evidence to support your statements given above by referring to specific points relating to any investigation reports or progress of the patient, treatment provided etc., which substantiate your observations
_____________________________________________________________________________
_____________________________________________________________________________
3 Describe the third most significant event:
Area of:
Consideration Concern
Adverse Event
Which:
Made no difference to outcome
May have contributed to death
Caused death of patient who would otherwise be expected to survive
Was it preventable?
Definitely
Probably
40 | Fraud Investigation and Medical Audit Manual
Proba
Defini
Don’t
Pleaspointetc., w
_____
Hosp
Recor__________
Concl
Prima ICD c Secon ICD c Antec ICD c
Was t
Yes
If NO,
_____ Paym
ably not
itely not
know
se provide evs relating to which substa
___________
ital mortality
rd the cause o______________________
lusion:
ary cause of d
code: ______
ndary cause o
code:_______
cedent cause
code: _______
there enough
, what informa
___________
ment:
vidence to suany investig
antiate your o
____________
y report revie
of death ( as g________________________
eath: ______
___________
of death:_____
____________
of death: ___
___________
h information
No
ation was lack
____________
upport your sation reportsobservations
___________
ew findings:
given) ______________________
____________
____________
____________
___________
____________
____________
n to come to
king?
___________
statements gs or progresss
____________
________________________
___________
___________
___________
____________
___________
___________
a conclusion
____________
iven above bs of the patie
___________
______________________
___________
____________
____________
___________
____________
____________
n?
___________
by referring tent, treatmen
____________
________________________
____________
___________
___________
____________
___________
___________
____________
to specific nt provided
___________
______________________
___________
___________
___________
___________
____________
____________
___________
_
__
_
_
_
_
_
Fraud Investigation and Medical Audit Manual | 41
Pre-auth approved amount:
Amount Claimed:
Amount Recommended:
Name of the first line assessor:
Designation
Date:
Signature
C
PRA
AnClaim
AYDHAN M
nnem AYUSHMAMANTRI
exuruditAN BHAJAN AR
re 6:t Fo
ARAT – ROGYA Y
: orm
YOJANA
A
Fraud Investigation and Medical Audit Manual | 43
A. Claim
1. N2. P3. N4. P5. P6. S
B. Docu
1 Dothe
2 Doinf
3 Ar
4 Ar
5 Do
6 Dothe
7 Wa
8 Fo
C. Any o
D. Final
Date:
Name an
m Specific IName of PatiPM-JAY cardName of HosPackage BooPackage AmoStatus of Cla
ument Valid
o the photose photo on thoes the inforformation mere the sympto
re investigati
oes the diag
oes the infore package bas the paym
or rejected ca
other remar
l Conclusio
nd Signatur
nformation ent:
d no.: spital: oked: ount: im:
dation
taken at thehe card? rmation menentioned on oms consist
on report ou
nosis match
rmation menblocked? ment for entir
ases, was th
rks
n
re of the inv
e time of adm
tioned on ththe claim do
tent with the
utcomes con
h the packag
tioned on th
re approved
he reason of
vestigator:
mission and
e card matcocuments? diagnosis?
nsistent with
e blocked?
e discharge
amount mad
f rejection jus
discharge m
ches with the
the diagnos
e card consis
de?
stified?
match with
e
sis?
stent with
Yes No
Annexure 7:Reporting Format
aYushMan bharaT – Pradhan ManTri Jan arogYa YoJana
Fraud Investigation and Medical Audit Manual | 45
Ann
exur
e 7:
Rep
ortin
g Fo
rmat
N
ame
of th
e st
ate
Guj
arat
Per
iod
of p
erfo
rman
ce
Dat
e of
sub
mis
sion
Tota
l No
of c
ases
trig
gere
d fo
r inv
estig
atio
n/au
dit
ab
Cd
ef
gh
Stat
e C
ode
(TM
S)To
tal P
reau
ths
rais
edTo
tal N
o of
cas
es tr
iger
red
for f
urth
er re
view
Tota
l am
ount
(v
alue
) of
ca
ses
that
wer
e tr
igge
rred
Tota
l No.
of
cas
es
inve
stig
ated
/ au
dite
d
% c
ases
in
vest
igat
ed/ a
udite
d ou
t of t
rigge
red
(G/
(C+D
+E))
Sys
tem
ge
nera
ted
case
s
Cas
es re
ferr
ed
by P
roce
ssin
g Te
am
Cas
es re
ferr
ed b
y C
laim
s R
evie
w/
Mor
talit
y C
omm
ittee
46 | Fraud Investigation and Medical Audit Manual
Out
com
esFi
eld
Inve
stig
atio
n
iJ
Kl
Mn
o
Tota
l am
ount
of
case
s w
here
frau
d w
as c
onfir
med
% c
ases
con
firm
ed
as fr
aud
of to
tal
inve
stig
ated
(I/G
)
Tota
l Cas
es s
ent f
or F
ield
In
vest
igat
ion
Num
ber o
f cas
es w
here
frau
d w
as
confi
rmed
afte
r fiel
d in
vest
igat
ion
Tota
l am
ount
of
case
s w
here
frau
d w
as c
onfir
med
pos
t fie
ld in
vest
igat
ion
Hos
pita
lBeneficiary
Hos
pita
lBeneficiary
Fraud Investigation and Medical Audit Manual | 47
Med
ical
Aud
itM
orta
lity
Aud
it
Pq
rs
Tu
Tota
l Cas
es s
ent f
or
Med
ical
Aud
itN
umbe
r of c
ases
w
here
frau
d w
as
confi
rmed
afte
r m
edic
al a
udit
Tota
l am
ount
of
case
s w
here
frau
d w
as c
onfir
med
pos
t m
edic
al a
udit
Tota
l Num
ber o
f m
orta
litie
sPe
rcen
tage
of
mor
talit
y au
dits
don
e N
umbe
r of
cas
es
whe
re d
eath
was
due
to
hos
pita
l neg
ligen
ce
48 | Fraud Investigation and Medical Audit Manual
Act
ion
post
Con
firm
atio
n of
frau
d
vw
XY
Za
aa
ba
Ca
d
Tota
l Num
ber
of h
ospi
tals
in
volv
ed in
fr
aud
Num
ber o
f ho
spita
ls
agai
nst w
hich
ac
tion
was
in
itiat
ed
No
of
hosp
itals
w
here
sh
owca
use
was
issu
ed
No
of
hosp
itals
re
port
ed
to S
EC fo
r su
spen
sion
No.
of
hosp
itals
de
empa
nelle
d
No
of
hosp
itals
pe
nalis
ed
Am
ount
of
pen
alty
re
cove
red
No
of
hosp
itals
ag
ains
t whi
ch
FIR
is lo
dged
Am
ount
of
puni
tive
Rec
over
ies
Mad
e
Fraud Investigation and Medical Audit Manual | 49
Ben
efici
ary
Aud
it (e
card
/go
lden
reco
rd)
ae
af
ag
ah
Num
ber o
f gol
den
reco
rds
crea
ted
in C
sCN
umbe
r of c
ases
sel
ecte
d
for a
udit
Num
ber o
f cas
es fo
und
frau
dule
ntA
ctio
n Ta
ken
(Lis
t the
ste
ps ta
ken
afte
r fra
ud is
con
firm
ed)
H
PRA
AnHand
SAY
DHAN M
nnedlinSitua
YUSHMAMANTRI
exurg DatioAN BHAJAN AR
re 8:iffic
onsARAT – ROGYA Y
: cult
YOJANA
A
Fraud Investigation and Medical Audit Manual | 51
HandInves
A. Non-verificQuerbe clo
B. Non-teamrejectdocu
C. Allegbrideout thof the
D. Casecase inves
E. Not asituatnot abasis
F. Verifteaminves
dling Dstigati
-cooperatiocation or bries/Remindeosed under
-cooperatio will be sendted and thement
gation of B/misbehave he actual face agency for
es missed oto investig
stigator
able to assition if system
able to assigs to investiga
fication of c will coo
stigator/intern
Difficulon and
n from benbeneficiary ier to beneficnon-coopera
n from Hosding three Q amount wil
Bribe/ Misbon particula
ct in the casr future case
out for invegator for inv
ign the casem is not worn the trigge
ate the case
cases on Hoordinate winal inputs on
lt Situad Audi
neficiary sidis not availciary to coopation/ non-su
spital/proviQueries/Rem
ll be recove
behave on ar investigatose, if allegaties
estigation/Vvestigation,
e to SHA inrking or therred case to without any
olidays: On th internaln telephone/
ations t
de: if there lable to ve
perate in verubmission of
der: if thereinder to hos
ered under n
investigatoor, will set uion found to
Verification:that need
nvestigator/re is any IT investigation
y fail.
any holiday l team/inve/mobile.
during
is low cooerification, thrification. if thf required do
e is non-coospital, if therenon-coopera
or: If thereup a third pa be correct,
If any caseto take it o
/NHA team issue, whern/FCM team
y or especialestigator te
g Field
operation frohe team where is no reocuments.
operation froe is no respoation/ non-su
e is any party to investaction to be
e missed ouon highest
due IT/ tecre our NHA m, will do this
ly on Saturdelephonicall
d
om beneficiawill be sendesponse, the
om Hospitaonse, the claubmission o
articular alleigation agene taken and
ut while asspriority to
hnical issueteam or FCs exercise o
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l/provider, aim will be of required
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igning the assign to
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PRA
AnTrig
AYDHAN M
nneggeYUSHMAMANTRI
exurer Po
AN BHAJAN AR
re 9:oint
ARAT – ROGYA Y
: ts
YOJANA
A
Fraud Investigation and Medical Audit Manual | 53
T
1.
2.
rigger
. Claim His
Impers Misma Claims Secon Claims Claims
hospit Claims Claims Same Exces Delibe Claims only li Claims
notes Multip
hospitthe be
Multip
. Admissio
Memb High n Repea Repea High n High n Admis Avera Exces High n
s Poin
story Trigge
sonation. atch of in-hos without signd claim in ths from multips from a hotal/residences for hospitas from membeneficiary
ssive utilizatierate blockins with incomne of treatms with missimissing in s
ple claims wittal of one meeneficiary fample claims tow
ons Specific
bers of the sanumber of adated admissated admissnumber of adnumber of adssion beyondge admissio
ssive ICU (Innumber of ad
nts
ers
ouse documegnature of thhe same yeaple hospitalsspital locate
e. alization at abers with noclaimed in mon by a spe
ng of higher-mplete/ poor
ent given, sng informati
surgical caseth repeated ember of themily unit, wards the en
c Triggers
ame beneficdmissions. ions. ions of memdmission in odmission in wd capacity ofon is beyondntensive Cardmission at t
ent with submhe beneficiarar for an acus with same ed far away
hospital alreo claim free ymultiple placcific membepriced packamedical histupporting doon like post
es. hospitalizatie beneficiary
nd of policy c
ciary family g
mbers of the odd hours. weekends/ hf hospital. bed capacite Unit) admthe end of th
mitted documry on pre-autute medical iowner. from benefi
eady identifiyears, i.e. reces at the saer belonging age rates to tory: complaocumentatiot-operative h
ion (under ay family unit
cover period
getting admit
same benef
holidays.
ty of the proission. he Policy Co
ments. thorisation follness/surgic
iciary’s resid
ied on a "waegular claim ame time.
to the benef claim highe
aints/ presenon vague or ihistopatholog
a specific polt and differe
d, close prox
tted and dis
ficiary family
ovider in a m
over Period.
orm. cal.
dence, phar
atch" list or bhistory.
ficiary Familer amounts. nting symptoinsufficient. gy reports, s
licy at different hospitals
ximity of clai
charged tog
y unit.
onth.
rmacy bills a
black listed h
ly Unit.
ms not men
surgical / an
ent hospitalsfor other me
ms.
gether.
away from
hospital.
tioned,
naesthetist
s or at one embers of
54 | Fraud Investigation and Medical Audit Manual
3.
4.
Claimsexpen
Claimsparticu
. Diagnosis
Diagn Diagn Claims
bite, s Ailmen Ailmen Multip
require One-ti Treatm
not eq Subst
Surgic Part o
amoun ICU/ M
critica Overa High
consu
. Billing an
Claims Multip Claims High v
consis Irregu
invest Claims
s for medicnsive investigs with Lengular ailment.
s Specific T
osis and treaostic and tres for acute m
snake bite etnt and gendent and age m
ple procedured. ime procedument of disequipped or eitution of pcal. of the expents receivedMedical Treal illnesses.
all medical mnumber of mption of fin
nd Tariff bas
s without suple specialty s where the value claimstent with aillar or inoigations. s submitted
cal managegations. gth of Stay
Triggers
atment conteatment in dmedical Illnetc. er mismatch
mismatch. res for sam
ure reported eases, illnesmpanelled fo
packages, fo
enses collec by the Insuatment bloc
management cases treat
nancial limit.
sed Trigger
pporting preconsultationcost of treat from a smment and/or
ordinately d
that cause s
ement admis
(LOS) whic
radict each oifferent geog
ess which are
h.
me beneficia
many timessses or accidor. or example
cted from brer.
cking done f
exceeds moted on an o
rs
e/ post hospins in a singletment is muc
mall hospitalr provider prdelayed sy
suspicion du
ssion for e
h is in sign
other. graphic locate uncommo
ary – blocki
s. dents for wh
, Hernia as
eneficiary f
for more tha
ore than 5 dout-of-pocke
talisation pae bill. ch higher thal/nursing horofile. nchronizatio
ue to format
exactly 24 h
ificant varia
tions. n e.g. encep
ing of mult
hich an Emp
s Appendic
for medicine
an 5 days o
ays, other thet payment
apers/ bills.
an expectedome, particu
on of tran
or content th
hours to co
ance with th
phalitis, cere
iple packag
panelled He
citis, Conse
es and scre
of stay, othe
han in the cabasis at a
d for underlyularly in clas
nsactions to
hat looks "to
over OPD t
he average
ebral malaria
ges even th
ealth Care P
rvative trea
eening in a
er than in th
ase of criticagiven prov
ying etiology.ss B or C
o avoid c
oo perfect" in
treatment,
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a, monkey
hough not
Provider is
atment as
addition to
e case of
al illness. vider, post
. cities not
concurrent
n order.
Fraud Investigation and Medical Audit Manual | 55
5.
Pharmphotoc
Claimssummadmisdocum
. General
Qualif Specia Delaye Conve Non-p Not di
macy bills copies. Perfes with visible
mary, bills ession to discment or docu
fication of praalty not avaied informatioersion of outpayment of trspensing po
in chronoloect claim filee tempering
etc. Same hcharge. X-rayuments witho
actitioner dolable in hospon of claim d-patient to inransportationost-hospitaliz
ogical/runnine with all critof documen
handwriting y plates without proper si
oesn't matchpital. details to then-patient casn allowancezation medic
ng serial neria fulfilled
nts, overwritiand flow i
hout date anignature, na
h treatment.
e Insurer. ses (compar.
cation to ben
number or with no defiing in diagnoin all documnd side prinme and stam
re with histor
neficiaries.
claim docciencies. osis/ treatmements from
nted. Bills gemp.
rical data).
cuments wi
ent papers, m first prescenerated on
th colour
discharge cription to
a "Word"
NOTES
NOTES
NOTES