Chaos reigns in medical insurance claims management at many tertiary-care government hospitals. Huge volumes of claims rejection — formerly under the RSBY (Rashtriya Swasthya Bima Yojana) and now under KASP (Karunya Arogya Suraksha Paddhati) — have snowballed into perennial financial crises at these institutions.
The issue came to a head at the Thiruvananthapuram and Alappuzha Medical College Hospitals (MCHs) last week after the Chamber of Distributors of Medical Implants and Disposables gave it in writing that it would be unable to replenish stocks of consumables in cath labs till the outstanding payments — ₹15.21 crore from the Alappuzha MCH and ₹20.06 crore from the Thiruvananthapuram MCH — are cleared.
The State’s failure in instituting a professional insurance management system even 11 years after running the RSBY can prove to be costly as these hospitals are now handling KASP, which offers a higher package of ₹5 lakh.
“The RSBY claim amounts due to us (rejected claims) would run into ₹16 crore or more. Under KASP, though we estimate the claims at ₹2.5 crore monthly, we have received only ₹90 lakh since April, ” says Thiruvananthapuram MCH Superintendent M.S. Sharmad.
Hospitals’ inefficiencies
However, sources at CHIAK (Comprehensive Health Insurance Agency of Kerala) revealed that improper documentation, inefficiency in filing claims properly, and lack of follow-up on rejected claims by MCHs have led to this state of affairs. While the Thiruvananthapuram, Kozhikode, Alappuzha, Kottayam and Thrissur MCHs had the highest claims rejection rate, the newer ones like Manjeri, Parippally or Ernakulam managed to get nearly 100% claims approved. SAT Hospital and General Hospital, Thiruvananthapuram, too have nearly 100% approval.
Onus on hospitals
“The onus is on the MCHs to ensure that their documentation leaves no room for rejection,” sources said.
“The Thiruvananthapuram MCH has 4,050 rejected insurance claims worth ₹31 crore during 2017-18. But it could produce case sheets and documents for just 1,700 cases before the Collector’s district grievances redressal cell (DGRC), which tried to verify the merit of rejected claims. It held 40 sittings but gave up the verification because of ‘non-cooperation by the MCH’,” a senior insurance official said.
No grievance filed
In 2018-19, the MCH had rejected claims for ₹19 crore. The MCH has employed 35 staff on contract basis for handling insurance claims under the RSBY. But it has not filed a single grievance before the DGRC to counter the arguments of insurance company, he added.
The government having moved into full insurance mode health financing schemes, it is imperative that government hospitals have a professional insurance management system for the systematic follow up of rejections. With total lack of monitoring and none owning up any liability, it is public funds which is going down the drain.
