| a · 2018. 12. 14. · fraud and a nce. The a, Accounta rrence and nti-Fraud Gu n capability e success nd audit me the suspect mplementa mplementatio nd verificatio al provisions

Fraud Investigation and Medical Audit Manual | a

NATIONAL HEALTH AGENCYDECEMBER 2018

FRAUD INVESTIGATION AND MEDICAL AUDIT MANUALAyushman BharatPradhan Mantri Jan Arogya Yojana (PM-JAY)

Fraud Investigation and Medical Audit Manual | iii

AytethGac

Gprul(Simrisfobe

WHfrafraAm

yushman Bertiary healthhan 40 per

Government occess to hig

Global experirograms notltimate respoSHA). Stronmpact on schsk faced by

or ensuring ee internalize

With this spirion’ble Healtaud and abaud actions udit Manual

manual to stre

Dr. InduChief ExeNational

harat – Prah coverage ocent of Indof India is likh quality hea

ience showst only resultonsibility to g anti-fraudheme financthe SHA, sta

effective imped and perme

it, the Nationth Minister ouse that couand build cfor PM-JAY

engthen the

Bhushan ecutive OfficHealth Agen

Mi

dhan Mantrof Rs. 5,00,0dia’s populakely to have althcare.

s that integrt in financiaeffectively p efforts are

ces and for sate and the

plementationeate all aspe

nal Health Aon 29th Auguld be perpecapacity in S

Y. We sinceremanageme

cer ncy

FORNation

inistry of HeGove

ri Jan Arogy000 to moreation at em

a significan

rity violationsal losses butprevent, dete important safeguardingscheme res

n of PM-JAY ects of mana

Agency has pust 2018 layetrated undeSHAs, NHAely hope thant of anti-fra

REWORnal Health Aealth and Fernment of

ya Yojana (Pe than 10 crompaneled ho

t positive im

s in health it have a muect, and detnot only frog beneficiaryulting from fand it is crit

agement of t

previously dying down ther PM-JAY.

A is proud toat state goveaud activities

RD Agency Family Welfa

India

PM-JAY) enore beneficiospitals. Th

mpact on the

insurance puch greater ter fraud lies

om the persy health butfraud. Hencetical that a “zthe scheme.

eveloped Anhe overall viTo bring un

o share the ernments pas in their res

fare

ndeavors to ary families

his unprecepoor and vu

rograms arer impact on s with the S

spective of rt also to mitie, SHA’s antzero toleran.

nti-Fraud Guision and roniformity andFraud Inves

articipating inpective state

offer secon, accountingdented effoulnerable po

e high. Fraupeople’s he

State Health reducing theigate any reti-fraud efforce” approac

uidelines, reoadmap for cd consistencstigation ann PM-JAY wes.

ndary and g for more ort of the opulation’s

ud in such ealth. The Agencies

e adverse eputational rts are key ch to fraud

eleased by combating cy in anti-d Medical ill use this

Fraud Investigation and Medical Audit Manual | v

Table of ConTenTsfraud and abuse ConTrol under PM-JaY .......................................................................................................... 1

obJeCTive of The Manual ........................................................................................................................................ 2

MiniMuM requireMenTs for audiTs and invesTigaTions ............................................................................... 2

ProCess flow and sTandard forMaTs .............................................................................................................. 3

1. Beneficiary Verification Audits ........................................................................................................................... 3

A. Process flow for audit of cases from CSC or Hospitals ............................................................................. 4

B. Process flow for audit of triggered cases after claims ............................................................................... 5

2. Utilization Audits ................................................................................................................................................. 6

A. Pre-Authorization Stage ................................................................................................................................. 6

B. During Hospitalization stage (live audits, before discharge) ..................................................................... 7

C. Claims Stage (post-facto audits, after discharge) ....................................................................................... 8

3. Mortality Audits.................................................................................................................................................... 9

Process flow for Mortality Audit......................................................................................................................... 9

4. Claims Audits ....................................................................................................................................................... 10

Process Flow ....................................................................................................................................................... 10

Code of ConduCT for sTaff handling field invesTigaTion and MediCal audiT .......................... 11

MonThlY rePorTs and Mis To be subMiTTed To nha ................................................................................ 11

anneXure 1: benefiCiarY audiT forM ........................................................................................................... 13

anneXure 2: MediCal audiT forM ................................................................................................................... 16

anneXure 3: field invesTigaTion forMaT .................................................................................................... 19

anneXure 4: on-siTe invesTigaTion forM .................................................................................................... 22

anneXure 5: MorTaliTY audiT forM ............................................................................................................... 30

anneXure 6: ClaiM audiT forM ........................................................................................................................ 42

anneXure 7: rePorTing forMaT ..................................................................................................................... 44

anneXure 8: handling diffiCulT siTuaTions .............................................................................................. 50

anneXure 9: Trigger PoinTs ............................................................................................................................ 52

Fraud Investigation and Medical Audit Manual | 1

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Thquantedapr

Frdocoor

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Thofrofradelean

Fraud a

he main objuality healthnd effective

ertiary care tata 2011) aractices at e

raud under tocuments orould result rganization.

M-JAY is gonti-fraud culfforts shall

ndependence

he NHA hasf fraudulent obust IT systaud capacitependent on

evel to invesnti-fraud trig

Table 1:

Fraua

Preventio

Detection

Deterrenc

and Ab

ective of PMcare servicecoordination

to the pooreat no cost toeach level.

the PM-JAYr misrepresein unauthoIt includes a

overned basture that pebe based

e, and Reas

s taken sevepractices at tem with a pty building tn the effectistigate fraudgers or by p

Fraud Man

ud managemapproaches

on

n

ce and Reco

buse C

M-JAY is to es in public n between dest of the poo them. The

Y shall mean entation madrized financ

any act that m

ed on a zeroermeates all

on five fosonability.

eral steps toall levels. T

proactive andrainings for iveness and, carry out a

processing te

agement ap

ment s

overies

Control

provide the and private

different stakoor and vulne also expos

and includede by a perscial or othemay constitu

o-tolerance aspects ofounding pri

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State Heald robustnessaudits and neams.

pproaches a

Ben Pro Pre Cla Dat Fie Co Enf Str

l unde

poor and vhospitals. T

keholders winerable (as ses a risk o

e any intentioon or organ

er benefit toute fraud und

approach tof the scheminciples: Tr

ection, prevee developmeraud control th Agenciess of the invenecessary ac

at different

St

neficiary ideovider empae-authorisatiaims manageta analytics

eld and Medintract manaforcement ofingent action

r PM-J

vulnerable poThe success ith a view toidentified byof leakages

onal deceptiization with o herself/himder any app

o any kind ofe’s governa

ransparency

ention, deteent of the Aand detectio

s (SHA). Thestigation action once t

stages of i

tages of im

entification annelment on ement cal Audits

agement f contractuans against th

JAY

opulation of of PM-JAY

o providing qy Socio Ecoin the form

ion, manipulthe knowledmself or so

plicable law i

f fraud and aance. The ay, Accounta

errence and nti-Fraud Guon capabilityhe success nd audit methe suspect

mplementa

mplementatio

nd verificatio

al provisions he offenders

f the countryassumes th

quality secononomic Castm of fraud a

lation of factdge that the ome other pn India.

aims at devepproach to

ability, Resp

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ation

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2 | Fraud Investigation and Medical Audit Manual

O

ThimantraPTrre

M

Thby

Objecti

his Investigmplementingnd recover ansaction/PMJAY impleransaction M

equired to su

Minimu

he Anti-Frauy the SHA u

Audi

Medical aud

Death audit

Hospital aud

Beneficiary hospitalisati

Beneficiary (post dischathrough telephone) Beneficiary discharge –home visit)

Pre-authoris

ive of t

ation manu robust andany fraud re-authorizaementation Managemenubmit month

um Req

ud Guidelinender AB-PM

t Type

dit

t

dit

audit (duringion)

audit arge –

audit (post – through

sation audit

the Ma

al has beend consistent losses unde

ation/Claims adopt standt System anly reports on

quirem

es developedMJAY. The sa

Table 2: R

Sam

5% of to

100% Each emleast twi

g 10% of t

10% of t

5% total

10% of tauthorisaspecialti

anual

n developedanti-fraud in

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dard practicnd for meaninn anti-fraud m

ments f

d by NHA spame are out

Recommend

mple for InsTPA Aud

tal cases ho

mpanelled hoce each yea

total cases h

total cases h

cases hosp

total pre- ations acroses

d by NHA investigation in different and payme

ces, formatsngful reportimeasures w

for Aud

pecifies the mtlined in Tab

ded minimu

surer / it

ospitalised

ospital at ar

hospitalised

hospitalised

pitalised

ss disease

in order to and audit sstages – f

ent. It is crits for data cng and anal

with results a

dits an

minimum sable 2 below:

um sample

Sam

2% direct 2% of audInsurer / T100% Each empa year 5% direct 10% of auInsurer/TP5% direct 10% of auInsurer/TP

2% direct 2% of audInsurer /TP2% of audInsurer / TInsurance 10% of au/ISA (for A

assist SHAsystems to dfrom benefitical that all capture for lysis purposchieved ther

nd Inve

amples for a

for audits

mple for S

audits + its done by t

TPA /ISA

anelled hos

audits + dits done by

PA /ISA audits + dits done by

PA /ISA

audits + its done by tPA /ISA its done by t

TPA /ISA for mode) dits done by

Assurance m

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estigat

udits to be c

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the

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Claims audiclaims)

n addition, thnsurance com

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he followingor each typeor investigatipecialized eormats applyowever, incltate without

. Beneficia

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benefi

Beneficiar

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it (rejected

he model tempany/ISA.

that SHAs ml/meet the a

Review Comd all the seelow mention

ss Flow

g sections pr. As per proion and med

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ary Verificat

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nce of e-cardation of servit Utilization iciary

ry audits for

er of entitled n either at a

10% of t

-

ender docum

may like to cbove require

mmittee and erious/repeatned processe

w and S

rovide overvovisions of Adical audit, hncies for cacies carryingnal checks, provisions la

tion Audits

at the level o

d (golden reces under th– Claim su

issuance of

family unde CSC or an

total claims

ments speci

carry out audements or m

Mortality & t fraudulentes.

Standa

view of auditAnti-fraud Guhowever undarrying out g out the tasprovisions, daid down un

of verification

cord) to a nohe scheme bubmitted by

f golden card

er PM-JAY cempanelled

fy minimum

dit and invesmay carry out

Morbidity Ret transaction

ard For

t and investuidelines, SHder certain cinvestigationsk of investidata captureder this man

n of benefici

on-eligible pby someone a provider

d to a non-el

an get a gol hospital

3% of audInsurer /TP10% of au/ISA (for A

100%

m requiremen

stigation of st the same a

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rmats

tigation procHAs are requcircumstancn and auditgation and ae and analysnual.

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person impersonatwithout act

ligible perso

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its done by tPA /ISA for Idits done by

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ude:

ting to be theual hospital

on

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mode)

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up at State lty cases fo

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may utilize sndard procer PMJAY. Sred for their

e beneficiaryization of a

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mode)

cases by

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esses and HAs may, particular

y an entitled

process of


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ficiary auditsaud triggersarge or post

audit of ca

s will also bes flag the clpayment.

ses from C

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SC or Hosp

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pitals

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ost admissiostage, pre-d

on in cases wdischarge st

where the tage, post


B. Proce

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ggered cas

es after claaims


2.. Utilization

A. Pre-A

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Authorizatio

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ase and mayneeded, reqproved denie

Case app

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tion stage, tSA. Fraud trmeets certaiy choose to quests for aded or referre

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e-auth team v

Desk Audit c

Addition

Do

ed

led health celoped by Ned criteria/triditional docucuments. Aftigation.

quest received

s flag pre-aut

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confirms claim

nal document

ocuments Rev

care providerNHA/SHA woiggers. The

uments or coter reviewing

d by SHA/IC/I

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ts requested

viewed

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ous

Case s

Send foInvest

-authorizatioe pre-auth repproval team

edical audit (ment, case m

suspicious

or further tigations

on request equest as m reviews (Annexure may either


B. DurinDuringsent fosent fomerits

g Hospitalizg hospitalizaor field inveor action/dens as in norma

zation stageation stage, stigation (Annial of pre-aal course.

Case

F

System getriggere

e (live auditsystem triggnnexure 3). uthorization

No

Case processe

meri

e sent for fiel

Fraud confirmdischa

enerated d case

ts, before dgered casesIf fraud is cand if confi

is ed on ts

Case dPre

d investigatio

med before rge

discharge) s, or the casconfirmed bermed as non

directed by the-auth team

on

es directed efore the disn-fraud, the

Yes

he

by pre-authscharge, thecase is proc

Casea

team are en case is cessed on

e sent for action


Sre

findm

offif

de

C. ClaimIn castriggerTheseensurelevel snaturealso bReviewinvest

Send eports and

dings to edical icer for final

ecision

ms Stage (pose of post-drs will highli

e cases are fe that any ascrutiny, thee of fraud trigbe triggered w Committeigation, then

InveConfi

ost-facto auischarge or ight certain first revieweapparent faln the case wgger and thebased on re

ee in the nn its report a

Fie

estigation irms Fraud

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ed by the Insse positiveswill be sent e evidence neview by Stanormal cournd findings a

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Yes

eld Investigat

NM

discharge)e of claim adsuspect” whsurance Coms are filteredfor field inveneeded for vate Claims Rse of their are shared b

iggered cases

ication by des

Fraud Suspect

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ud Confirmed

sent for actio

Yes

tion or on-site

Needs further Medical Audit

djudication/ hich would nmpany/ ISA fd out. If theestigation orverification (Review Comfunctions.

by Medical O

s

sk audit

d

n

Ye

e investigatio

tIn

payment ofneed to be for prima-fac case remar medical au(refer annexmmittee andIf fraud is

Officer for th

Casmed

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No

Ye

es

on

nvestigation case as non

f the claim, investigatedcie/ fact veri

ains suspectudit dependix 3,4). The c Mortality & confirmed e final decis

e sent for dical audit

Case osed

es

confirms n fraud

the fraud d/ audited. ification to t post first ing on the

cases may Morbidity

after field sion.

Case closed


3.

As regdesk acommclaim docum

In boInvestmatter

. Mortality

As per Anbe requirereviewed in case oMorbidity

Process

Evea b

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Fin

gards casesaudit or field

municate his may be sen

mentation wh

th cases, ttigator, on-sr.

Audits

nti-Fraud Gued to provideand verified

of death dueCommittee f

flow for Mo

ery death ocrief death such network iew/examineims submiss

ate Mortality ath cases al decision w

s triggered/md audit depefinal finding

nt for field ihich may hav

the Medicalite investiga

idelines, 100e all the rele by the audi

e to negligefor final revie

ortality Aud

ccurring in thummary

hospital to e the causesion

and Morbid

would be tak

marked for mending on thgs to the Mnvestigationve been coll

l officer wilation team a

0% mortalityevant informait team to id

ence. All casew and deci

dit

he network h

constitute e of death a

dity Committ

ken by State

medical audhe facts to edical office

n followed bected during

ll review thand Medical

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hospital sho

a Mortality nd the repo

tee to scree

e Mortality an

dit, the Medbe verified t

er for his finby a medicag the first sta

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uld be referreecified in Aneal cause of tality must b

uld be intim

Audit commort shall be

en and cond

nd Morbidity

dical Auditorto confirm t

nal decisionl audit teamage.

tions and fhile taking a

ed for auditsnexure 5 andeath and t

be put up to

ated to SHA

mittee and submitted to

duct detailed

y Committee

r may also cthe suspicio. In some c

m to review

findings of final decisio

s. The hospitnd the sametake necesso State Mor

A within 48 h

this commio SHA at th

d mortality a

.

conduct a n and will

cases, the additional

the Field on on the

tals would e would be ary action rtality and

hours with

ittee shall he time of

audit of all


4.

. Claims A

There maby the Insrandomly mentioned

Claim ISA / S

Randoeach p

Process Trigge Medic

submi SHA t

require

Audits

y be some fsurance com

selected cad as Annexu

Review comSHA and apomly review provider eac

Flow ered cases ocal doctor of ssion and shakes a final ed.

fraud cases mpany/TPA/ Iases or triggure 6.

mmittee shalpealed by th/ audit at lea

ch quarter.

or randomly sthe audit teahares reportdecision ba

which may ISA/ SHA. Tgered cases

ll Review 10he provider;ast 2 percen

selected appam validatest with findingsed on the r

initially go uTo identify sus is done o

0 percent cl

nt of the pre-

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aims that ar

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cases are aents submitt

gs and takes

and incorrectit becomes ic basis. Th

re rejected b

ons and 3 pe

assigned to tted by the ho

s disciplinary

tly approvedimportant th

he reporting

by the Insure

ercent of the

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d and paid at audit of format is

er / TPA /

claims of

am ing claims

erever


CIn

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To main To carry

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and aud To alwa

and prod To alwa Not to g

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Monthl

he SHAs areo control frauaken againsthe progress ction as nee

monthly repor

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ed be. Refert format to b

duct fo and M

t standards ogation/audit

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mit the same uthorization/me to hospitdignity of pa

sion of extraSHA under

orts an

o submit moalysis, cases

parties, notes, draw co

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or StafMedica

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health data/to competenpermission tal/beneficiaatient and soaneous authPM-JAY

nd MIS

nthly report s investigatedices, issued

omparative aure 7 for theat district le

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nal conduct ut disrupting

information nt authority from compery as the caocial norms hority of any

S to be

by 7th of evd and audite

d, recoveriesanalysis, proe format of

evel for their

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collected d

etent authorse may be during bene

y kind while

Subm

very month toed and the rs made etc. ovide furthethe report. own referen

ield

y in all situatng in ‘treatm

uring the co

rity to condu

eficiary intervacting on b

mitted t

o NHA listingresults there

This would er support a

It is suggence and deta

tions ment of bene

ourse of inv

uct investiga

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to NHA

g the measueof and punit

enable NHAnd feedbacsted to the

ailed analysi

eficiary’ in

vestigation

ation/audit

HA or any

A

ures taken tive action A to track k, to take SHA that s.

B

Ben

PRA

Anefic

AYDHAN M

nneciary

YUSHMAMANTRI

exury AuAN BHAJAN AR

re 1:udit ARAT – ROGYA Y

: For

YOJANA

rm A


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A. Patien

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Dis5. Co6. Me

S. No.

1.

2.

3.

4.

5.

6.

B. Gener

1. W

2. If h

3. Ha

4. In

5. W

6. W

7. W

nt Informati

M-JAY FAMIame: ather’s or Huddress: strict: ontact No. embers regis

Name

ral Informat

here was the

hospital, was

as s/he avail

which hospi

hat symptom

hen did s/he

hen did s/he

on

ILY ID: ____

usband’s nam

stered:

P

tion

e E card ma

s the benefic

led services

ital did s/he

ms were the

e get admitte

e get dischar

__________

me:

State:

M-JAY ID number

ade?

ciary charge

under PM-J

utilize the se

patient exhi

ed?

rged?

Annexure 1

________

ed any mone

JAY? If yes -

ervices?

ibiting when

1

P

Gender

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-proceed fur

he/she visit

Pin Code:

Ag

card? If yes,

rther

ted the hosp

ge Re

, how much?

pital?

elationship

?


8. Fo

9. W

10. W

11. If aye (4

C. Match

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Name an

or how many

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es, take phot

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other remark

mmendatio

nd Signatur

y days was s

vided free fo

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, is there a stograph of th

the informa

of the bene

k or observ

n of the Au

re of the Au

s/he hospital

od?

iven?

scar on the bhe same)

ation provide

eficiary bein

vation:

ditor:

ditor with D

Annexure 1

lized?

body, which

d by the ben

ng interview

Date:

1

could help in

neficiary with

wed with the

n verification

h the one re

e one subm

n of the surg

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mitted in TM

gery. (If

e TMS)

MS

Annexure 2:Medical Audit Form

aYushMan bharaT – Pradhan ManTri Jan arogYa YoJana


Options for answer selection

Remarks

S. No. Criteria1 Pertaining to Clinical Information (Patient history and evidence of

physical examination is evident)a. Is the chief complaint recorded? Pl look for package specific complaints Yes/ No

b. Is History of present illness (HOPI) mentioned? Should have Onset, duration and progress of relevant symptoms/ signs

Yes/ No

c. Are relevant personal history of beneficiary noted (positive or negative)? Viz, abuse of tobacco/ alcohol/ intoxicating substances consumption? (the next Q get enabled if answer to this Q is YES)

Yes/ No

d. Is the above positive history relevant to having caused the package diagnosis?

Yes/ No

e. Does this above history (whether captured or not) makes the package NOT applicable as per exclusion policy?

Yes/ No

f. Is a report on relevant physical examination available? Pl look for package specific findings

Yes/ No

g. Is general examination and other systems (CVS, CNS, AS, RS) done and findings reported? Pl look for package specific data

Yes/ No

2 Progress notes from admission to dischargea. Are admission notes and detailed findings at admission notes available? Yes/ No

b. Are daily recorded progress reports available? Pl look for package specific sequential information, which should have been captured.

Yes/ No

c. Is each progress report signed and dated? Yes/ Nod. Are reports of patient’s progress filed chronologically? Yes/ No

e. Are Specific instructions to discharge the patient and line of treatment after discharge captured in ICP's?

Yes/ No

f. Is a Discharge summary available? Yes/ Nog. Does the discharge summary capture all details of presenting features,

investigations, line of treatment given during stay line of treatment advised at discharge and (Select <No> if investigations and all treatment details, missing as follow up will be not be rational)

Yes/ No

h. Are instructions to follow up explicitly given? Yes/ No3 Pathology/ laboratory/ Radiology reports Scrutiny (only one of the 2

sets a-d or e-f have to be answered ) a. If it is a Medical / emergency surgery Package, Are pathology/

laboratory reports available Yes/ NA

b. Are reports relevant to package, the diagnosis and treatment given? Package specific list

Yes/ No

c. If it is a Medical / emergency surgery package, Are radiology reports available?

Yes/ NA

d. Are reports relevant to package, the diagnosis and treatment given? Package specific list

Yes/ No

e. If it is a planned surgery package, Are justifying lab/ radiology / Frozen section/ FNAC/ biopsy reports available?

Yes/ NA

f. Are reports relevant to package diagnosis, the diagnosis and treatment given? Package specific list

Yes/ No

4 Is an operation report available? (Only for surgical Packages) Yes/ No

This Surgery Is more likely to be Planned surgery/ emergency surgery/ could be either emergency or planned surgery.

Is Pre-op Profile Available (Relevant to Package, Age & Co-morbidities)

Yes/ No

Modified Medial Audit Qs


4A. Planned surgery- Yes/ NAa. Does the report include Pre and post-operative diagnosis (Both should be

same)?Yes/ No

b. Is the correct package blocked? Yes/ Noc. Are the justifications of arriving at the diagnosis rational? Package

Specific list Yes/ No

d. Is the date and time of procedure mentioned? Yes/ Noe. Is the surgeon who has operated same as the name given while blocking

the package?Yes/ No

f. Is the surgeon’s signature available on records? Yes/ No4B. Emergency surgery Yes/ NAg. Does the report include pre-operative diagnosis? Yes/ Noh. Does the report include post-operative diagnosis? Yes/ Noi. Are the above two similar? (Need not be exactly same) Yes/ Noj. Was the decision to operate rational w.r.t clinical features? Yes/ Nok. Are the justifications of arriving at the diagnosis specified? Yes/ Nol. Is the date and time of procedure mentioned? Yes/ No

m. Is the surgeon who has operated same as the name given while blocking the package?

Yes/ No

n. Is the surgeon’s signature available on records? Yes/ No5 Documentation scrutiny

a. Do all entries in medical records contain signatures? Yes/ Nob. Are all entries dated? Yes/ Noc. Are times of treatment noted? Yes/ Nod. Are signed consents for treatment available? Yes/ Noe. Is patient identification recorded on all pages? Yes/ Nof. Are all nursing notes signed and dated? Yes/ No

6 Does the claim fall under any clause of Schedule 2 - Exclusions to policy Yes/ No

Auditor's Conclusion Red/ Amber/ GreenSpace for adding observations basis which this conclusion is arrived at

Annexure 3:Field Investigation Format



Reason for field validation Routine claims review medical audit request

Name of Patient Gender RelationPM-JAY card no. or State Specific scheme No. Address

Name of Hospital - Address of Hospital -

Hospital ID (if available)

Hospital Existence Yes NoResponse from Hospital Co-operative Non Co-operative IndifferentIs Hospital Registered DGHS Yes No Reg. No. No of BedsNo of OTPathology/ Diagnostics Inhouse Out sourced Not Available Type of Hopsital Public PrivateName of Treating DoctorSpecialityDr Registration NumberContact Number of Treating DoctorDate and time of Hospital Admission as per hospital file Date and time of Hospital Discharge as per hospital file Type of Treatment Surgical ConservativeIf MLC/FIR, not available then specify the reasonsDiagnosis:

Yes No

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Yes NoYes No

D. Patient profile Patient Photograph collected with ID card (upload)Patient Id's proof Collected (upload)

Was he/she operated upon, if yes, is there a scar on the body, which could help in verification of the surgery.(If yes, take photograph of the same)

C. Documents Review: Observations noticed for each parameter need to be entered in terms of completeness, errors, overwriting or any discrepancies noticed

Any other remark or observation:

Is IPD CollectedIf yes, please upload If no specify the reason Indoor Register Entry Verified (upload)

Has any money been charged so far? If yes, how much?

Deatiled progress notes reflecting evaluation of each visit, reason for visit is documented as relevant

E. Patient/Attendent interview in the hospital

Annexure 3 - Field Investigation Format

B. Facility inspection: Need to match against the details submitted at the time of empanelment and claim submission

A. Patient/Claims Details

What symptoms were the patient exhibiting when he/she visited the hospital?

All Medical Histroy of patient documented (upload)Pateint clinical information is documented (upload)Is there any previous hospitalization of same patient at the same hospital Past history details documentedComplete Medication list on chart and nursing chart (upload)Findings and follow ups are documented (upload)

Hospital Lab Register Verified (upload)Treating Doctor Certificate Verified (upload)


When did the patient got admitted? Is the patient admitted since then?Was the patient informed about the name and value of the package which was blocked by the hospitalWhat diagnostic tests (if any) were performed on the patient?



Comment of Investigator

Final Opinion of the Investigator GenuineFraudAbuse

Name of Investigator

Signature of Investigator

Investigation Date & Time

District/State official Siganature

Past History Details (Non Mandatory)

Name of DiseaseDuration prior to

getting admitted Only Yes/NO

High Blood pressure Yes NoDiabetes Yes NoAsthma Yes NoCancer Yes NoIHD/MI Yes NoTobacco Yes NoAlcohol Yes NoOthers



F. Home Visit: Patient/Attendent interview after discharge

Was post-hospitalization medication provided to the patient? Was any money asked by the hospital at any point of time. If yes, then how much and for what purpose?Was patient or the attendant asked to purchase any the medicine or carry on any of the diagnostic test attheir own cost? Does the patient have any receipt for the same? (If yes, take photograph of the same)

Was the patient given a discharge summary? Does the patient still possess that discharge summary? If yes physically verify the same

Has s/he availed services under PM-JAY? If yes -proceed further. In which hospital did s/he utilize the services? What symptoms were the patient exhibiting when he/she visited the hospital?

What was the treatment given? If any surgery, is there a scar on the body, which could help in verification of the surgery. (If yes, take photograph of the same)

When did s/he get admitted? When did s/he get discharged?

Was the patient informed about the name and value of the package which was blocked by the hospital

For how many days was s/he hospitalized?Was s/he provided free food and travel allowance?

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Section 4.

1. Deat H H P P N A S L C C E D D

2. Prog

A H W W

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M P W W A

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1. and 4.2. is t

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provide a sumon, chronolog

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re there any s/No

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of operation

f operation (

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experience o

experience o

erative period

s this patient/No

o, should this/ No

ummary

mmary of thgy of events

ssessment

areas of CO

rformed? Yeareas of Co

e was perform

kup/fitness fo

(too late, too

ess

ing of OT

of surgeon d

of surgeon o

d

t treated in a

s patient hav

e Case in th up to death

ONCERN or

es/ No oncern, or Ad

med, or trea

or surgery/tr

o soon, wron

deciding

operating

a critical care

ve been prov

he form of nh of the patie

ADVERSE

dverse Even

tment provid

reatment

ng time of da

e unit (ICU o

vided critical

narrative – inent –

EVENTS in

nts in any of

ded?

ay)

or HDU) duri

l care in ICU

ncluding com

n the manage

the following

Yes N

ing this adm

U/HDU?

mplaints at th

ement of thi

g?

No NA

ission?

he time of

s patient?


Opinion

-

If there a

Describe

Note any

Note if th

Made no

May have

Caused d

Was the know

Section

Hospital

Primary c

ICD code

Seconda

ICD Cod

Antecede

ICD code

FINAL R

1. _____2.______3.______

of the Aud

Minimal/ M

any areas of

e the significa

y areas of co

hese areas c

difference t

e contributed

death of pat

death preve

D: Record o

l mortality a

cause of dea

e: ________

ary cause of

e: ________

ent cause of

e: ________

RECOMMEN

_______________________________

it committe

Mild/ Modera

CONCERN

ant event/s d

oncern or Ad

caused any o

to outcome _

d to death__

ient who wo

entable? (i) D

of cause of

audit comm

ath: _______

___________

death: ____

__________

f death: ____

___________

NDATIONS (

________________________________

ee regarding

ate/ Severe

or ADVERS

during the co

dverse Event

of the follow

__________

__________

uld otherwis

Definitely (ii

death

mittee review

__________

__________

___________

___________

__________

__________

if any) OF T

_______________________________

g overall ris

SE EVENTS

ourse of trea

t

ing:

___________

___________

se be expect

i)Probably (

w findings:

__________

__________

__________

__________

__________

__________

THE MORTA

_______________________________

sk of death

S in the mana

atment in the

___________

__________

ted to surviv

(iii) Probably

___________

___________

__________

__________

___________

___________

ALITY AUDI

________________________________

agement of t

e hospital:

__________

__________

ve_________

y not (iv) De

__________

__________

___________

___________

__________

__________

IT COMMITT

______________________________

this patient:

___________

_________

_________

finitely not (

_________

________

_______

_____

_________

________

TEE

________ ________ ________

______

(v) Don’t


Attestati

N

1

2

3

Date:

ion by the M

Name

Mortality Auudit Commit

Designatio

ttee membe

on

ers:

Signat

ture


First Line Assessment Form on Hospital Mortality Audit Report

Case Note Review

A case note review is a peer assessment of the death of a patient. It should be carried out in a spirit of sympathetic enquiry and provide sufficient detail for a clear view of events. Points should be made in a detached manner and any opinions expressed should be objective and reasonable.

Aim

The aim is to ascertain the proportion of patients who died because of 'problems in care', defined as patient harm resulting from healthcare processes including acts of omission (inactions), such as failure to diagnose and treat, or from acts of commission (affirmative actions) such as incorrect treatment or management.

Criteria for Ranking

An area of CONSIDERATION is where the clinician believes areas of care COULD have been IMPROVED or DIFFERENT, but recognises that it may be an area of debate.

An area of CONCERN is where the clinician believes that areas of care SHOULD have been better.

An ADVERSE EVENT is an unintended injury caused by medical management rather than by disease process, which is sufficiently serious to lead to prolonged hospitalisation or to temporary or permanent impairment or disability of the patient at the time of discharge, or which contributes to or causes death


Section A: General Information

Patient details:

Name:

Age: Sex: Pre-auth No.

DOA: DOD:

Diagnosis:

Reviewing Doctor:

Please provide a summary of the Case in the form of narrative

___________________________________________________________

Section B: Case Note Assessment

Were there any areas of CONSIDERATION, of CONCERN or ADVERSE EVENTS in the management of this patient?

Yes

No

1 Describe the most significant event:

Was surgery performed? Yes No

Were there any Areas of Consideration, of Concern, or Adverse Events in any of the following areas if an operation was performed? Discussion points Yes No N/A Pre anaesthetic check up/fitness for surgery Decision to operate Choice of operation Timing of operation (too late, too soon, wrong time of day) Intra-operative process Problems in functioning of OT Grade / experience of surgeon deciding Grade / experience of surgeon operating Post operative period


If yes above, provide details of

Area of:

Consideration

Concern

Adverse Event

Which:

Made no difference to outcome

May have contributed to death

Caused death of patient who would otherwise be expected to survive

Was it preventable?

Definitely

Probably

Probably not

Definitely not

Don’t know

Please provide evidence to support your statements given above by referring to specific points relating to any investigation reports or progress of the patient, treatment provided etc., which substantiate your observations

______________________________________________________________________________

2 Describe the second most significant event:

______________________________________________________________________________

Area of:

Consideration Concern

Adverse Event

Which:





Was it preventable?

Definitely

Probably

Probably not

Definitely not

Don’t know

Please provide evidence to support your statements given above by referring to specific points relating to any investigation reports or progress of the patient, treatment provided etc., which substantiate your observations

_____________________________________________________________________________

_____________________________________________________________________________

3 Describe the third most significant event:

Area of:

Consideration Concern

Adverse Event

Which:




Was it preventable?

Definitely

Probably


Proba

Defini

Don’t

Pleaspointetc., w

_____

Hosp

Recor__________

Concl

Prima ICD c Secon ICD c Antec ICD c

Was t

Yes

If NO,

_____ Paym

ably not

itely not

know

se provide evs relating to which substa

___________

ital mortality

rd the cause o______________________

lusion:

ary cause of d

code: ______

ndary cause o

code:_______

cedent cause

code: _______

there enough

, what informa

___________

ment:

vidence to suany investig

antiate your o

____________

y report revie

of death ( as g________________________

eath: ______

___________

of death:_____

____________

of death: ___

___________

h information

No

ation was lack

____________

upport your sation reportsobservations

___________

ew findings:

given) ______________________

____________

____________

____________

___________

____________

____________

n to come to

king?

___________

statements gs or progresss

____________

________________________

___________

___________

___________

____________

___________

___________

a conclusion

____________

iven above bs of the patie

___________

______________________

___________

____________

____________

___________

____________

____________

n?

___________

by referring tent, treatmen

____________

________________________

____________

___________

___________

____________

___________

___________

____________

to specific nt provided

___________

______________________

___________

___________

___________

___________

____________

____________

___________

_

__

_

_

_

_

_


Pre-auth approved amount:

Amount Claimed:

Amount Recommended:

Name of the first line assessor:

Designation

Date:

Signature

C

PRA

AnClaim

AYDHAN M

nnem AYUSHMAMANTRI

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YOJANA

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A. Claim

1. N2. P3. N4. P5. P6. S

B. Docu

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D. Final

Date:

Name an

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PRA

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AYDHAN M

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NOTES

NOTES

NOTES