High insurance claims rejection rate for MCHs

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Incomplete documentation of hospitals blamed for rejection of RSBY claims that run into crores

Government medical college hospitals (MCHs) in the State are a harried lot as pending health insurance claim payments due to these institutions under the Rashtriya Swasthya Bima Yojana (RSBY) now run into several crores.

However, even as the hospitals blame the insurance companies for non-payment of money due to them, experts point out that hospitals should instead make medical documentation and processes perfect so that the chances of claims getting rejected by insurance companies are less.

Onus on hospitals

“Insurance companies go through every claim with a fine-toothed comb. Unless hospitals can ensure that every claim is supported by proper case sheets, medical records, and documents, claims will naturally get rejected,” a health official said.

High RSBY utilisation

In Kerala, where the utilisation of the RSBY has been very high, though the number of hospitals empanelled under the scheme is almost equal (281 government hospitals and 300 private hospitals), nearly 70% of the insurance claims are put up by government hospitals.

Thus nearly 50% of the premium paid by the government is ploughed back into the public health system, to be utilised for the development of these hospitals.

However, with a claim rejection rate of 68% (2017-18) and nearly ₹20 crore to be received as pending claim amount, the Government Medical College, Thiruvananthapuram, (GMCT), now says that the hospital development society is in the doldrums.

It is the same story in other government MCHs too, all of which have pending RSBY claims ranging from ₹22 to ₹1 crore

“The insurance company is denying us payment saying that all our claims are under process. They also harass us asking for 500 case sheets at a time, the retrieval of which is not an easy process,” a senior GMCT administrator complained.

Even if the insurance company rejects a claim, hospitals can approach the district grievances redressal committee (DGRC), headed by the District Collector, or again go on appeal to the State-level committee, and try to get the claims approved.

“It all depends on how well the hospital keeps its medical documentation. If the GMCT has a claim rejection rate of 68%, it is just 5% at SAT Hospital, and 0.2 % at Govt Tribal Speciality Hospital at Kottathara, near Attappady,” sources said.

₹30,000 coverage

The RSBY, which started small, now has over 35 lakh beneficiary families and while claims have gone up many fold, the system capacity building has not been adequately supported. The RSBY offers an annual health coverage of ₹30,000 per beneficiary family.

Even in the 10th year of the RSBY, there is no system to analyse claim rejection pattern and to find solutions for the same.

Lack of pre-authorisation of procedures under RSBY is another reason for the mess that hospitals find themselves in, health experts said.

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