6.0 Brief Introduction:

The medical bills submitted by the executives for themselves as well as their dependent family members and the same are reimbursed as per MDL Medical Attendant Rules.

6.1 Background:

As a part of preventive vigilance function,a spot check of Invoices pertaining to Medical Bills/claims of the Executives was carried out for a period of six months. Out of 12 sample claims, prima facie some suspicion arosein five claimsand the same were investigated in detail. In one case, an amount greater than the claimed amount was reimbursed. In some cases, there exists some grey area to determine whether the surgical treatment was cosmetic or non-cosmetic. Though, the expert/ third party opinion was obtained in addition to the views of MDL Doctors as well as the treating doctors, it was difficult to define the type of surgery (i.e. whether cosmetic or non-cosmetic)in absence of complete reports/information. It was also observed that in such cases of specialised treatments, where MDL’s doctors may not possess adequate expertise/knowledge and there may be an element of doubt, the advice of third Party Expert doctor was not obtained to understand the proposed treatment plan and to adjudge the admissibility of medical claim as per MDL Medical Attendant rule.

6.2 Implementation:

As a systemic improvement in certification of Medical bills in line with MDL Medical Attendant rules,following was suggested and the same was implemented by issuing necessary directives from the competent authority.

a) In the case of admission in a Panel Hospital, the Credit Note should be issued only after receipt of Admission Request Note (ARN) duly filled, signed & stamped by the Hospital Administration. The Medical Officer of MDL who is authorized to issue Credit Note should get him/herself satisfied with the content of the ARN. If required, clarifications may be sought from the treating Doctor who has signed it. Also, Third Party Expert Opinion may be sought in respect of cases where the MDL Medical Officer has doubt w.r.t admissibility of the proposed line of treatment as per MDL Medical Attendant Rule.

The Medical Dept. should make sufficient provision in the Capital budget to get expert opinion in the event of requirement and to make payment of their professional fees for rendering the services.

b) In the case of admission to a Non–Panel Hospital, the employee should obtain consent of CMO/Nominated Medical officer, preferably 24 hours prior to the hospitalization, if it is a planned/Non-Emergency Case. In case of emergency, the employee should intimate to the Medical Dept. about the hospitalization (self or dependents) within 48 Hours from the time of hospitalization. Also, the treating Doctor’s letter indicating major complaints, status of the patient at the time of admission, diagnosis and proposed line of treatment etc. should be attached. The communication should be addressed to the CMO and should be sent via Fax / Email/WhatsApp or by submitting a memo to the Medical Dept. as per the viability of the employee.

c) In the case of certification of hospitalization claims of panel/non-panel hospitals, a standard check list for areas of concern pertaining to Medical, SB(HR&ER) & Finance-Payroll Section should be prepared, considering all aspects which are essential for proper scrutiny of the claims e.g. claim amount by the hospital/employee, certification & payment made against the same. Under no circumstances, the certified amount should be greater than the claimed amount by the hospital/employee. If some legitimate claim is missed out by the employee, the same should be separately dealt with and be considered subject to submission of the claim by the employee along with supporting documents.

d) The list of the items which are non-Payable in accordance with MDL Medical Attendant Rule, should be updated regularly. A comprehensive list should be hosted on the MDL’s portal for transparency. The deduction proposed by the Medical Dept. should be clearly indicated on the tax invoice and the same should be supported with back up calculation.

e) The hospitalization claims should be properly acknowledged on the covering letter submitted by the Hospital/Employee. The main page of the Tax Invoice should be certified by CMO or nominated medical officer with the applicable remarks.

f) Upon receipt of the claim in the Medical Dept., it should be first sent to CMO for his/her noting and thereafter it should be marked to the Medical Officer concerned by CMO if the claim is to be scrutinised/certified by MO other than CMO.

g) Any Communication amongst Medical, HR & Finance-Payroll Section, regarding hospitalization claim, should be carried out through proper Office Memo with clear-cut indication of “Remarks/special attention, if any”.

h) In spite of implementation of above steps, if by oversight/ negligence of any of the employees, it is observed that the claimant is in receipt of extra payment than the claimed amount, the onus is on the claimant to report such incidence to the authorities concerned immediately so as to take corrective action promptly. Failure to report such incidence by the employee should be viewed seriously.

i) The data entry of the hospitalization claims should be carried out in Medical Dept. by deploying adequate manpower to cater the need. Also, confirmation regarding dependency and other aspects {Ceiling Limit of Hospitalization Claims, Dependent Status, Cases of recovery of the Non-Approved Hospitalization Claims pertaining to other than Critical (Super Speciality) diseases should be verified and obtained from concerned HR office.

j) All Employees should be asked to maintain the record of Hospitalization, Consultation, Diagnostic Tests Reports & Medical History pertaining to themselves and their dependents. The same should be shared with the Medical authority of MDL as and when requested.

6.3 Impact and Benefits:

With the implementation of the above mentioned Systemic improvement, the possibility of excess/undue payment against admissible medical claims is eliminated.

Back