Dr YSR Aarogyasri Health Care Trust (Government of Andhra Pradesh)

1. Dr YSR Aarogyasri Health Care Trust (Government of Andhra Pradesh) “Insight from scheme Data” 30th September and 1st October - 2019 “Towards Universal Health Coverage”

2. Health Schemes under Dr YSR Aarogyasri Health Care Trust Total Population covered : 4.24 Crs

3. Disease wise utilisation under the scheme for the FY 2018-19

4. Disease wise amount spent by the Government for the FY – 2018-19

5. High performing Hospitals during the FY 2018-2019

6. District wise Therapies Preauthorized for the FY 2018-19

7. Cochlear Implantation programme:- The scheme has been designed as a special package to provide cashless services to the needy hearing impaired deaf and dumb children with package amount of Rs.6.5 lakhs per beneficiary towards Cochlear Implantation Surgery and Audio Verbal Therapy for one year. 513 hearing impaired children are benefited from cochlear implantation programme till date. Patients utilization From 02.06.2014 to 31.08.2019

8. “ Inclusion of Maternal Procedures” The Government of A.P in order to further reduce the Maternal Mortality Rate from 65 to 50 per one lakh live births has launched “Talli Suraksha”. The objective of the scheme is to provide cashless Obstetrics services under Dr. YSR Aarogyasri for BPL beneficiaries on par with CGHS 2014 rates, thereby reducing the burden on Govt. Hospitals. The date of implementation of “Talli Suraksha” is on 15.01.2019. New Obstetric (Deliveries) Procedures included under the Dr.YSRAarogyasri and utilization from 15.01.2019 to 31.08.2019.

9. Mechanism for identifying frauds committed by the Hospitals Panel doctors & Operations wing - Technical Scrutiny (who are processing the Preauths and Claims) Internal Medical Audit of 1% Claim paid cases. External Clinical audit by the third party Agency. Disciplinary committee Monitoring tools for effective implementation of the schemes Flagging system Biometric Mechanism – For IP registration, Discharge, MEDCO, Dialysis & Oncology sessions. SMS services regarding the status of the case (Preauth and after Claims approval) Online Grievance workflow (from Mithra to GM – Grievance) 104 Toll free call centre (Seva Kendram) & 104 Outbound call services Real Time Governance (RTGS) survey - Evaluation by Third Party (by Govt.) .

10. Flagging system • There is a provision in online system to raise flag from Vaidya Mithra (field staff) to the Executive officer (Trust) level. • Flags due to Complaints – Money Collection, Denial of Treatment, Post OP complication, Incomplete Treatment, Delay treatment, adverse complaints, etc., • flags for want of Technical verification – Verification of genuineness of case like Emergency approvals, enhancements, high end packages, Death cases, Special opinions, Specialist opinions, etc., • The case with flag for Money Collection will be out of regular claim process and processed in a separate workflow till redressal.

11. 104 (Tollfree) - Inbound and Outbound Services Inbound Services: The Trust has established a dedicated helpdesk/ helpline “104 SevaKendram” (Health Information Help Line) which functions round the clock (24x7) 365 days. This Toll-Free Call Centre provides the following services Health Advice, Counselling Services, Availability of beds and specialty in the Network Hospitals, Information regarding the schemes implemented by the Trust Aarogyasri/EHS/WJHS Any citizen can book a complaint through 104 Tollfree Call Centre and by online mechanism further action will be initiated till redressal. Out bound Services: The Trust initiated Outbound services in 2013 by calling each & every beneficiary after discharge in a defined format with a questionnaire taking the feedback under Dr YSR Aarogyasri and EHS. The satisfaction % is 94 and complaints will be forwarded to Grievance Section of concerned departments for redressal.

12. Real Time Governance (RTGS) – Govt. The Government is conducting independent evaluation by third party through Real Time Governance – Satisfaction percentage is 88 % as on November, 2018

13. Medical Audit • Internal Medical Audit: • The Trust designed an online workflow for conduct of Medical Audit in the year 2013. • 1% of all Claim paid cases will be displayed in the Medical Auditor login for auditing in a defined format. • Criteria for 1 % selection of cases – All Death cases, high end procedures, high volume procedures including special cases for audit, etc. • Special audit will be conducted for Death cases & others due to negligence of NWHs / Fraudulent cases and Disciplinary action will be initiated by EDC. • Interaction with Operations team on Medical audit Observations and updating of Guidelines.

14. Medical Audit • Clinical audit by External Agency: • The Board of the Trust has decided to setup a Medical Audit system by outsourcing through a Third Party Agency during the meeting held in 2008. • As per the agreement with Network Hospitals all the Hospitals shall under go Medical Audit. • The Trust identified Medi Assist Agency for conducting Clinical Audit. • As per the MOU Agreement: • 1. Appointment of one Clinical Director and one Clinical Auditor for conducting Clinical Audit. • 2. 2 % of Claim paid cases are to be audited.

15. Disciplinary Actions • Reasons for disciplinary action • Infrastructure Deficiencies • Equipment Deficiencies • Manpower deficiencies • Service Deficiencies • Violation of service Contract Agreement(SCA) • With holding of Payments • Levy of Penality • Suspension • De-empanelment • Delisting

16. Thank you