Community Health Insurance model for IKP "SANJEEVANI"


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Community Health Insurance model for IKP "SANJEEVANI"

  1. 1. Community Health Insurance Model for Indira Kranthi Patham Sanjeevini
  2. 2. Objectives <ul><li>Improve the quality of life through various healthcare initiatives thereby reducing the severity of poverty resulting from health related catastrophes </li></ul><ul><li>Provide quality Healthcare services at affordable costs </li></ul><ul><li>Community Development through Health education on Preventive Health, Nutrition and Sanitation </li></ul>
  3. 3. 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.
  4. 4. 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
  5. 5. Benefits of the Scheme <ul><li>Free OPD consultation </li></ul><ul><li>Discount on Diagnostics </li></ul><ul><li>Hospitalization Cover for Surgeries </li></ul><ul><li>Hospitalization Cover for Medical Conditions admission for family </li></ul><ul><li>Community Development Activities </li></ul><ul><li>Treatment to be taken at Network Hospitals Only </li></ul><ul><li>Treatment in General ward only </li></ul>
  6. 6. 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 Medicines 1.    Free of cost at PHC level 2.    Discounted rate at NWH ( drug depots of Velugu) Services under the Scheme
  7. 7. 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 Hysterectomy General Surgery Gastroenterology Orthopaedics – includes fracture surgeries Genito-Urology Endocrinology ENT. 100% Cashless facility
  8. 8. 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.
  9. 9. Diagnostics <ul><li>Investigations like X-ray, Blood tests, Urine tests Ultrasound CT, MRI, etc covered </li></ul><ul><li>Can be done at Network Hospitals at special discounted rates </li></ul>
  10. 10. Health Insurance model for Primary Healthcare <ul><li>Providing Primary healthcare to the residents . </li></ul><ul><li>Creating chain of Village health centers with telemedicine connectivity. </li></ul><ul><li>Consultation with MBBS doctors, basic investigation and quality medicines are provided at VHC free of cost. </li></ul>
  11. 11. Cashless Service at Network Hospitals <ul><li>ID cards will be issued to every member enrolled. </li></ul><ul><li>Member produces card at Network hospitals to avail of services. </li></ul><ul><li>Hospital seeks pre-authorization from ZS for giving cashless service or any planned procedure </li></ul><ul><li>Based on eligibility, ZS gives authorization to Hospitals to start treatment. </li></ul><ul><li>Member to undergo the required treatment </li></ul><ul><li>Member will sign on claim form, at discharge </li></ul><ul><li>He pays only for exclusions under the scheme. </li></ul>
  12. 12. Premium <ul><li>For 4 lives-Rs. 260/year </li></ul><ul><li>Premium Collection - One time Upfront payment </li></ul>
  13. 13. Benefits   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 exclusions 10% of the final bill Non-medical expenses, Implants like stents, valves & Other exclusions
  14. 14. Comparison with other Insurance Schemes   Other insurance schemes Our Scheme Premium Approx 1000 < Rs 260/- Pre-existing diseases Not covered Covered Coverage Upto 1 lakh ? 30000 OPD paid Free Diagnostics Paid at hospital rate Approz 50% discount Medicines Buy at market rate Buy from NWH pharmacy at discounted rate or Velugu Drug Depots
  15. 15. <ul><li>Prosthesis and Implants including Valves, Grafts Mesh, Stents, Nails, Screws, Spectacles, Hearing Aids </li></ul><ul><li>Transplants </li></ul><ul><li>Cosmetic Surgery </li></ul><ul><li>Malignancies – Chemotherapy, </li></ul><ul><li>Angioplasty </li></ul><ul><li>Autoimmune diseases </li></ul><ul><li>Vaccination </li></ul><ul><li>Dental surgeries </li></ul><ul><li>Dialysis </li></ul><ul><li>Vitamins and Tonic </li></ul><ul><li>Ambulance Services </li></ul><ul><li>Food and other Non Medical expenses </li></ul><ul><li>Any other expenditure, which are not related to illness/hospitalization </li></ul>Exclusions
  16. 16. <ul><li>Implementing Agency (Zilla Samakhaya will act as TPA) </li></ul><ul><li>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 </li></ul><ul><li>Maintaining member database </li></ul><ul><li>Arrange for cashless treatment for the beneficiary in </li></ul><ul><li>Network Hospital by issuing pre-authorization </li></ul><ul><li>Claims Processing and settlement </li></ul><ul><li>Maintenance of accounts </li></ul><ul><li>Generation of periodic report on utilization (statistics) </li></ul><ul><li>Administer the scheme, avoiding misuse and fraud </li></ul><ul><li>Appoint required manpower to monitor, manage and maintain the scheme. </li></ul>
  17. 17. 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
  18. 18. Hospital Accreditation Process Flow 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 agreement Training of Hospital co-coordinator regarding the Protocol Updating of Database Communication to IKP/ZS MMS/VO HSC
  19. 19. Enrollment <ul><li>Village Organization will take the responsibility of Enrollment </li></ul><ul><li>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 </li></ul><ul><li>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. </li></ul><ul><li>As soon as members get the ID card they can avail the treatment at NWH </li></ul>
  20. 20. 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
  21. 21. Availing the Treatment Beneficiary goes to Network hospital with ID Card, Receipt Admission for Surgery 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 Free OPD Consultation Investigation Special rates
  22. 22. 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
  23. 23. 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. Sent to VO Rep for verification A-Eligibility Verification ID card, Receipt, Residential Proof B-Medical verification Data entry into Software START STOP Letter of Rejection to Hospital Authorization letter to hospital Medical Officer checks and fixes rate Letter of Rejection to Hospital NO Complicated/General/ Exceptions
  24. 24. Claim <ul><li>The Claim Form from the Hospital should be accompanied by </li></ul><ul><li>Photocopy of the I.D. Card </li></ul><ul><li>Original claim form with the signature of the beneficiary. </li></ul><ul><li>Final split – up bill – with the signature of the beneficiary raised in the name of “ZS.” </li></ul><ul><li>Original authorization issued by ZS </li></ul><ul><li>Original discharge summary </li></ul><ul><li>Operation Note from treating Doctor (Incase of surgery) </li></ul><ul><li>Original Investigation and Lab Reports </li></ul><ul><li>List of consumables prescribed </li></ul>
  25. 25. Claims Flowchart Receipt 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 supporting Documents Collection of DD Dispatch o hospital Complete Incomplete
  26. 26. Process of Reimbursement to NWH <ul><li>Claims checked for required documents </li></ul><ul><li>Medical scrutiny of the Claim by ZS medical officers </li></ul><ul><li>DDs dispatched to the Hospitals </li></ul><ul><li>  </li></ul>
  27. 27. Controls and quality checks <ul><li>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 </li></ul><ul><li>ZS coordinators (Case Managers) </li></ul>
  28. 28. Obligations as a NWH <ul><li>All Network Hospitals (NWH) shall display a board with “Scheme Name” in Telugu prominently at the reception. </li></ul><ul><li>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 </li></ul><ul><li>The package rates mentioned are all exclusive of the implants and the prosthesis. </li></ul><ul><li>The beneficiaries under the Scheme will be entitled only for General Ward Admission </li></ul>
  29. 29. OPD Record Investi gations Specialty Address Age/ Sex ID No Name of Patient S. No
  30. 30. Surgery Statistics Report Date: Amount Pre-autho No. Specialty Name of surgery Date of Admission Address Age& Sex ID No Name S No
  31. 31. OPD Statistics Weekly Report Name of the Hospital Place Statistics From: To:
  32. 32. IPD Weekly Statistics Report Name of the Hospital : District :- Surgery Statistics From: To: No. of surgeries/Medical Admissions performed for the current week :-
  33. 33. Details of Investigations