Role Of Doctors In Cashless Service

Dr Biswendu Bardhan

Cashless service is becoming popular. It has been recorded that around 15-65 per cent of the hospital revenue comes from credit facility provided by the hospitals and all departments/staffs including the clinicians/consultants/doctors have a major role to play in cashless service. It has been found that more than 60-70 per cent cases rejected by the insurance companies/TPAs are because of the discrepancy of the information provided. It is commonly found that the details filled in the pre-authorisation form and patient history recorded in the indoor case paper or in the discharge card don’t match. In such cases, claims get rejected even if the cashless is given to hospitals leading to bad debts for hospitals and strained relationship with the TPAs/insurers/corporates.

Though a few hospitals have started recovering from clinicians/doctors at fault for the rejected cases, the situation needs attention from top management. There are some guidelines which hospitals can request their consultants to follow, which can reduce rejection cases.

• The TPA cashless application form/pre-authorisation form has to be filled up completely. It is better to record patients’ contact number in the pre-authorisation form as well.
• All fields in the form are to be filled legibly, precisely and specific to whatever is asked, as misinterpretation can lead to confusion.
• Duration of present and past ailments have to be accurately and compulsorily mentioned. Specifically, one needs to mention the durations in terms of ‘A’ days, ‘B’ months or ‘C’ years. Sometimes in an emergency or while treating an unconscious patient, when detailed history is not possible to record, in such cases the detailed history needs to be recorded after the patient is conscious and immediately intimated to the TPAs/insurers.
• In case a patient has been admitted for a particular disease or ailment and develops complications or is found to have some other disease, the TPA/corporate/insurer needs to be informed about the same.
• In maternity cases, complete obstetric history has to be mentioned in terms of Gravida Parity Lifebirth Abortion.
• In road traffic accident cases, positive/negative report for ethanol abuse is mandatory. This can be mentioned in the request form itself. If that is not mentioned in the pre-authorisation request form and later found through clinical history, the case will be rejected.
• In case of patients with ‘multi-organ failure’, the HIV report has to be sent to the TPA. The cashless request will be processed only after the TPA receives the HIV report.
• TPAs/insurers need to be informed immediately if the patient is HIV positive, has history of drugs intake or have a history of exposure or the patient is in the hospital because of his/her suicidal attempt. This does not amount to breach of confidentiality.
• Admission for evaluation/investigations only are not payable under insurance. Any investigations/evaluations that can be done on an outpatient basis and does not warrant hospitalisation is not payable under insurance. So doctors should not accept the request of the patient in admitting them for evaluation/investigations.
• Provisional diagnosis has to be given.
• There is a need to provide the line of management in detail in the designated column in the form. Doctors may issue a certificate on their hospital letterhead giving the detailed line of treatment, in case the space provided in the form is insufficient.
• In case of surgery, the name of the surgery to be performed is to be mentioned in the form.
• In case of any change in the plan of treatment/diagnosis during the course of hospitalisation, the same needs to be intimated to the insurance TPA immediately, in the form of certificate issued on the doctor’s/hospital’s letterhead and a second approval has to be sought for the same. This is necessary because the revised diagnosis may become ‘Not Payable’ as per the policy condition.
• The break-ups of the categories mentioned in the form have to be provided. The doctor needs to provide the break-up for investigations, medicines, surgery and professional fees. In case the doctor is not in a position to fill in the room rent estimate, it may be left blank. It shall be completed at the billing section.
• The details in the discharge summary should match the information provided in the request form. If not, there is a chance that insurance companies/TPA may deny to cover the case, in spite of issuing prior approval.
• Doctors should advise investigations, which are required for the patients.
• Doctors should preferably not misguide the patients by incorporating fear of infections by advising general anaesthesia for minor procedures which any clinicians will prefer to do by local anaesthesia. For instance, a simple extraction of a carious premolar tooth in an adult doesn’t require general anaesthesia (GA). Hence, GA should not be indicated in such cases for the sake of admitting the patients and trying to get it financed by the TPAs and insurance companies.
• Do not change records of duration of ailments on request of patients or relatives.
• Patients should not be admitted to the hospital on their request, unless their condition warrant hospitalisation. Any misrepresentation/misinformation/intentional non-disclosure of facts should be avoided as that could lead to legal action.
• If the patient was referred from other hospital, it is necessary to record and mention the referral history and the reason for referral.

These guidelines are only indicative and have been taken from the industry experience. These can aid in reducing the number of rejection cases or making the process of cashless transaction smoother. Thus, along with the streamlining of the credit facility process, we need active participation from the doctors and other staff in creating value to the patients.

The writer is Senior Networking Officer, Western Region, Family Health Plan Limited.
Email: biswendu@gmail.com