Group Four
Frauds in Mass Health
Prevention
Detection
Correction
The PDC approach
1
Fraud in Mass Health

Why?
Geographical spread
Nature of business (Smart cards…smarter frauds)
Sarkari Paisaa…hamara adhikaar.
Break even post empanelment.
2
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
3
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
4
Audit Process
Treatment blocked/Claimed
Data synchronization
Data analysis
Auto SMS to investigator
Triggers
Field/Hospital Audit
Beneficiary complaint to SNA Call Canter
Verification done within 24hrs
Authentication by Doctor’s panel
Field/Hospital verification
with
Local Administration
Authentication by Doctor’s panel
Report to SNA
Continuance with
RSBY
Report to SNA within 48 hrs
If found
genuine
If found genuine
Representation
at SNA
Indecisive
Field verification
By SNA
5
If found guilty
De-empanelment
If found guilty
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
6
Same Patients – Multiple Blocks
URN
Name,
Gender
Date of
Admission
Date of
Discharge
Amount
Category
Final Diagnosis
00065421095392631
Nanku Ram,
Male
08-Nov-10
15-Nov-10
11,250
GENERAL
Fissurectomy and
Haemorrhoidectomy
00065421095392631
Nanku Ram,
Male
08-Nov-10
15-Nov-10
2,000
IL- Cardiac iIlness (Non
interventional illness)
IL-Angina
00065421095392631
Nanku Ram,
Male
08-Nov-10
15-Nov-10
883.25
IL - Infectious disease
IL-Tropical infection with
complication
00065421095392631
Nanku Ram,
Male
08-Nov-10
15-Nov-10
750
IL - Infectious disease
Enteric Fever
00065421095392631
Nanku Ram,
Male
02-Dec-10
06-Dec-10
1,384
IL- Respiratory illness
IL-Pnemonitis with
COMPLICATION
00065421095392631
Nanku Ram,
Male
02-Dec-10
06-Dec-10
3,915
IL- Cardiac iIlness (Non
interventional illness)
IL-Arrhythmias

Patient was blocked for fissurectomy and haemorrhoidectomy,
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.
7
Angina , tropical
Same patient - Multiple admissions
URN
Date of
Admission
Date of
Discharge
Amount
Final Diagnosis
Patient Details
00060671241526904
01-Aug-10
04-Aug-10
875
IL-Acute excerbration of COPD
Jesingbhai
00060671241526904
01-Aug-10
04-Aug-10
3,000
Enteric Fever
Jesingbhai
00060671241526904
24-Aug-10
26-Aug-10
4,500
IL-Status asthmatics
Jesingbhai
00060671241526904
06-Sep-10
13-Sep-10
720
IL-LBA
Jesingbhai
00060671241526904
06-Sep-10
13-Sep-10
3,000
Enteric Fever
Jesingbhai
00060671241526904
23-Oct-10
26-Oct10
1,000
MMD-General!
Jesingbhai
00060671241526904
01-Dec-10
03-Dec-10
1,500
MMD-General!
Jesingbhai
00060671241526904
01-Dec-10
03-Dec-10
1,500
MMD-General!
Jesingbhai

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.
8
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
9
Thank You
10