Effective linkage and Support supervision under Health Insurance Mr. Pankaj Kumar Bansal. I.A.S., Managing Director, CMRL

Linking to other programmes UHC NHM RBSK RCH DEIC Differently abled Dental packages Mental Health The CMCHIS can be linked to other Govt. Programmes. This can help in leveraging the benefits of the National programs and CMCHIS. By this we can also expand the coverage of CMCHIS towards Universal Health Coverage. But attending to primary care including RBSK, we can avoid morbidity due to dormant diseases. The primary care can also help us reducing the health expenditure on a long run.

Expansion of CMCHIS to cover Thalassemia and other blood disorders The Blood disorders are more common in tribal populations in Tamil Nadu. The CMCHIS can expand to cover the treatment for Thalassemia and other major blood disorders. The NGOs in the tribal region who are already giving medical care can be contract with bed grants. The expenditure by the NGOs can be partly covered by CMCHIS.

Community monitoring in health insurance Co-ordinating with JD and DD health of the district Tapping the PHCs for effective awareness on DC Procedures that can be prescribed by PHC Doctors Health camp schedules with range of speciality screenings Joint camps by services providers in the single venue. SHGs and other local bodies to mobilise local public for screening camps. SHGs to ensure that the drug distributed is undertaken asper the course. SHGs should ensure patient feedback on investigations recommended by screening doctors. Co ordinating with JD and DD Health for understanding the disease load of the location . Analysing the percentage of smart card distributed and co relating it with state incidence rate of state bench mark to understand/monitor justified incidence.

Challenges in monitoring and rectification of errors The monitoring of utilisation and misuse can be effected by periodic verification of the documents, facility inspections and beneficiary reviews. Any defects in the review can be addressed by imposing penalties and / or suspension of empanelment. Any out of pocket expenditures can be handled by repayment to the beneficiaries and penalty imposition. The strict enforcement of the penalties and suspension may affect the beneficiaries from accessing care from these facilities.

Challenges in regulating Govt. Health facilities Adherence of guidelines Poor knowledge of platform Usage Uploading of documents both in Preauth and claim level Delay in Submission of Preauth Preauth Applied after the surgery without securing EI Numbers Preauth applied after the discharge of patients Delay in Claim Submission Improper and inadequate documents Poor response for need more info for both preauth and claims No linkages between TNMSC and DC Procedures conducted

Improving the Utilization in Govt. Health Facilities The Govt. health facilities can be retrained in the workflow of the application software and the process of insurance claims. The protocols and the user manuals can be made available in the the website. The software helpdesk can be established to rectify the software issues which may cause the delay in claim submission. Special camps can be held for Govt. Health facilities to facilitate the interaction with the TPAs to sort out the long standing NMIs and other issues causing delay in claims.

Thank You