Community Health Insurance model for IKP "SANJEEVANI"
-
Upload
maxisurgeon -
Category
Documents
-
view
264 -
download
0
Transcript of Community Health Insurance model for IKP "SANJEEVANI"
Community Health Insurance Model for
Indira Kranthi Patham
Sanjeevini
Objectives
Improve the quality of life through various healthcare initiatives thereby reducing the severity of poverty resulting from health related catastrophes
Provide quality Healthcare services at affordable costs
Community Development through Health education on Preventive Health, Nutrition and Sanitation
Proposed Model
Network Partners
Network the Hospitals at Mandal Level Super Specialty hospitals at Dist level
Tie-up with NWH to provide consultation by Lady Doctor at PHC once in a week.
Benefits
Preventive Healthcare- Community Development, Education on Nutrition and Sanitation
Medical Conditions
Free OPD consultation, Discount on Drugs & Diagnostics
Surgical Conditions
At Village level through Heralth Assiastants and Health Workers
Refferal Hospitals
Referral Hospitals
Referral Hospitals
Benefits of the Scheme
• Free OPD consultation• Discount on Diagnostics• Hospitalization Cover for Surgeries• Hospitalization Cover for Medical Conditions
admission for family• Community Development Activities
Treatment to be taken at Network Hospitals Only Treatment in General ward only
Out Patient Consultation
PHC level: consultation with lady doctors once in a week Network Hospital (NWH): consultation free of cost
Diagnostics:
Basic diagnostics will be done at PHC level free of cost
Diagnostics at NWH will be done at a fixed discounted rate.
Quality Medicines1. Free of cost at PHC level2. Discounted rate at NWH ( drug depots of Velugu)
Services under the Scheme
Medical and Secondary and Tertiary Surgical Care: through Referral Network Hospitals, up to a maximum amount of 30000/-Covers more than 1650 surgeries –includes all categories of complex and common surgeries, OBG – includes normal delivery, LSCS and HysterectomyGeneral SurgeryGastroenterologyOrthopaedics – includes fracture surgeriesGenito-UrologyEndocrinology ENT.
100% Cashless facility
Hospitalization cover: Family floater hospitalization policy
Cover- Inpatient treatment requiring hospitalization for more than 24 hours. Maximum amount payable is Rs 5000/- under the Family Package 4. Cover would include consultation, investigation and room charges, medicines and consumables.
Bed charges, doctor fees and Investigation charges will be fixed.
10% of Co-Payment on the final bill.
Diagnostics
• Investigations like X-ray, Blood tests, Urine tests Ultrasound CT, MRI, etc covered
• Can be done at Network Hospitals at special discounted rates
Cashless Service at Network Hospitals• ID cards will be issued to every member
enrolled. • Member produces card at Network hospitals
to avail of services. • Hospital seeks pre-authorization from ZS for
giving cashless service or any planned procedure
• Based on eligibility, ZS gives authorization to Hospitals to start treatment.
• Member to undergo the required treatment• Member will sign on claim form, at discharge • He pays only for exclusions under the
scheme.
Premium
• For 4 lives-Rs. 260/yearPremium Collection - One time
Upfront payment
OPD Medical Admission Surgical Treatment
Doctor’s fees Free Free Free, Included in package
Length of stay 2 Admission/Family Till fit for discharge
Medicines/consumables
Buy from Biocare or NWH Pharmacies
Included in the Package
Free, Included in Package
Investigations Pay discounted rates Included Free, Included in package
Bed charges included Included in package
Oxygen, ventilator etc
Beneficiary to pay for
Included in package
Nursing charges Included Included
What do you pay for?
OPD diagnostics oxygen Ventilator & other exclusions10% of the final bill
Non-medical expenses, Implants like stents, valves & Other exclusions
Benefits
•Prosthesis and Implants including Valves, Grafts Mesh, Stents, Nails, Screws, Spectacles, Hearing Aids
•Transplants
•Cosmetic Surgery
•Malignancies – Chemotherapy,
•Angioplasty
•Autoimmune diseases
•Vaccination
•Dental surgeries
•Dialysis
•Vitamins and Tonic
•Ambulance Services
•Food and other Non Medical expenses
Any other expenditure, which are not related to illness/hospitalization
Exclusions
Implementing Agency (Zilla Samakhaya will act as TPA)
The ZS is responsible for the day-to-day operation of the Scheme. The duties will include, Ensure service standards at provider Network for hospitalization and Diagnostics
• Maintaining member database
• Arrange for cashless treatment for the beneficiary in
• Network Hospital by issuing pre-authorization
• Claims Processing and settlement
• Maintenance of accounts
• Generation of periodic report on utilization (statistics)
• Administer the scheme, avoiding misuse and fraud
• Appoint required manpower to monitor, manage and maintain the scheme.
PHC/Network Hospitals: PHCs and Hospitals enrolled under the scheme to provide services to the members of the scheme.
Responsibility:
Quality Treatment to members
Free Consultation and Discounted Investigations
START
STOP
Hospital approaches ZS with application
Inspection of Hospital facilities by ZS Representatives
Representative forwards recommendation to IKP
Site visit and Inspection by IKP Evaluation of the Hospital as per the Standards of accreditation Generation of the Inspection report on Services and facilities Submission of Report to Committee (IKP+ZS)
Final approval from Committee
Formal tie-up of the hospitals tripartite agreementTraining of Hospital co-coordinator regarding the Protocol
Updating of Database
Communication to
IKP/ZS MMS/VO HSC
Hospital Accreditation Process Flow
Enrollment• Village Organization will take the responsibility of Enrollment
• VO will collect the Enrollment from and Premium from the member and deposit with the Mandal samakhaya, hence MS will collect the premium of their Mandal and deposit with ZS
• ZS will issue ID cards in 15 days time to MS. MS will issue them to VO. VO will issue the cards to the members.
• As soon as members get the ID card they can avail the treatment at NWH
STOP
START
VO Representatives deposits the Fee to MS or ZS Bank account
Generation of Photo ID Cards and covering letters
VO Reps forwards enrollment forms to ZS
Data from Enrollment form entered into software
Attestation by VO Representative. Issuance of Receipt to member
Collection of Fee and photograph taken
Distribution of ID to members by VO Reps
Dispatch of ID Cards to VO Reps
Enrollment Filled by Member
Availing the Treatment
Beneficiary goes to Network hospital with ID Card, Receipt
Admission for Surgery
Free OPD Consultation
InvestigationSpecial rates CASHLESS
Hospitalization
Admission for Medical
treatment
Patient pays only 10% of co-payment
Member signs on the Claim Form
START
Discharge
Intimation to ZS by NWH
Pre-Authorization- from ZS
Preauthorization Method:
When a beneficiary is advised surgery/medical treatment by NWH, the Hospital sends a Pre-authorization to the ZS office seeking approval to conduct the surgery under the Scheme. The medical officer at the ZS approves the Preauthorization if all documents and requirement is in order.
In case of emergency, the Coordinating Officer at NWH shall take verbal sanction from the Implementing Agency and proceed with the surgical/medical treatment. The preauthorization for the same shall be sending to the Implementing Agency within 24 hours.
Documents to be sent: Photocopy of the ID Card
Preauthorization Flowchart
General Exceptions Sent to Hospital for supporting reports verification
Eligibility
Yes
Complicated cases
Eligible
No
Receive of Intimation from Hospital
Generation of Pre-Authorization Serial No.
Complicated/General/ Exceptions
Sent to VO Rep for verification
A-Eligibility VerificationID card, Receipt, Residential Proof B-Medical verification
Data entry into Software
START
STOP
Letter of Rejection to HospitalAuthorization letter to hospital
Medical Officer checks and fixes rate
Letter of Rejection to Hospital
NO
Claim
The Claim Form from the Hospital should be accompanied by
Photocopy of the I.D. Card
Original claim form with the signature of the beneficiary.
Final split – up bill – with the signature of the beneficiary raised in the name of “ZS.”
Original authorization issued by ZS
Original discharge summary
Operation Note from treating Doctor (Incase of surgery)
Original Investigation and Lab Reports
List of consumables prescribed
Claims FlowchartReceipt of claims
From NWH
Communication To Hospital
Communication To Hospital
Claim ID Generation
Document verification
Medical Scrutiny and Claims Processing
Approved Claims
Outward
Letter Of Settlement To the Bank By ZS
Claim pending for supportingDocuments
Collection of DDDispatch o hospital
Complete
Incomplete
Process of Reimbursement to NWH
Claims checked for required documents
Medical scrutiny of the Claim by ZS medical officers
DDs dispatched to the Hospitals
Controls and quality checks
Periodic quality check of Labs and Hospital service audit will be carried out by the ZS. Continuous failure to keep prescribed standards and conditions set by the ZS would result in disciplinary action against the NWH and Lab
ZS coordinators (Case Managers)
Obligations as a NWH
•All Network Hospitals (NWH) shall display a board with “Scheme Name” in Telugu prominently at the reception.
•Under the scheme, the beneficiaries are entitled to Free Out Patient services. No amount shall be collected as Registration Charges or Consultation Charges. On no account shall any amount be collected from the individual beneficiaries when admitted for surgical procedure
•The package rates mentioned are all exclusive of the implants and the prosthesis.
•The beneficiaries under the Scheme will be entitled only for General Ward Admission
OPD Record
S. No
Name of Patient
ID No Age/ Sex
Address Specialty Investi gations
Surgery Statistics Report Date:
S No
Name ID No
Age& Sex
Address Date of
Admission
Name of surgery
Specialty
Pre-autho No.
Amount
OPD Statistics Weekly Report
Name of the Hospital PlaceStatistics From: To:
Speciality No.Total upto this week
1 Cardiac Surgery2 Cardiology3 General Surgery4 General Medicine5 Neurology6 OB & G7 Ophthalmology8 Orthopaedics9 Paediatrics
10 Urology11 Vascular Surgery
T O T A L
IPD Weekly Statistics ReportName of the Hospital : District :-
Surgery Statistics From: To:
Sl.No. Surgery/Medical Admission Speciality NoTotal upto this week
12345
No. of surgeries/Medical Admissions performed for the current week :-
Details of Investigations
Investigations No.
Total upto this week
1 Albumin2 Blood Grouping3 Blood Sugar4 Blood Urea5 CBC6 Cholestrol7 CKMB8 CPK9 Createnine
10 CT Scan11 Direct12 ECG13 Echo14 ESR15 HDL