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Group Four

Group Four. Frauds in Mass Health P revention D etection C orrection The PDC approach. Fraud in Mass Health . Why? Geographical spread Nature of business (Smart cards…smarter frauds) Sarkari Paisaa…hamara adhikaar. Break even post empanelment. A stich in time saves nine: Prevention.

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Group Four

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

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

  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. What & who to investigate • Triggers • Frequency of triggers ( daily, weekly, periodical) • Approach of Investigation ( High moral stand..no) • Post investigation approach • Showcause notice, blocking TID’s, depanelment

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

  6. Triggers Triggers - 0301 • 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 - 0303 • 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

  7. Same Patients – Multiple Blocks • 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.

  8. Same patient - Multiple admissions • 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.

  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. Thank You

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