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Community Health Insurance Model for Indira Kranthi Patham Sanjeevini

Community Health Insurance Model for Indira Kranthi Patham Sanjeevini. Objectives. Improve the quality of life through various healthcare initiatives thereby reducing the severity of poverty resulting from health related catastrophes Provide quality Healthcare services at affordable costs

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Community Health Insurance Model for Indira Kranthi Patham Sanjeevini

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  1. Community Health Insurance Model for Indira Kranthi Patham Sanjeevini

  2. Objectives Improve the quality of life through various healthcare initiatives thereby reducing the severity of poverty resulting from health related catastrophes Provide quality Healthcare services at affordable costs Community Development through Health education on Preventive Health, Nutrition and Sanitation

  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. Benefits Referral Hospitals Surgical Conditions Referral Hospitals Medical Conditions Refferal Hospitals Free OPD consultation, Discount on Drugs & Diagnostics At Village level through Heralth Assiastants and Health Workers Preventive Healthcare- Community Development, Education on Nutrition and Sanitation

  5. Benefits of the Scheme • Free OPD consultation • Discount on Diagnostics • Hospitalization Cover for Surgeries • Hospitalization Cover for Medical Conditions admission for family • Community Development Activities • Treatment to be taken at Network Hospitals Only • Treatment in General ward only

  6. Services under the Scheme 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 Medicines1.    Free of cost at PHC level2.    Discounted rate at NWH ( drug depots of Velugu)

  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 HysterectomyGeneral SurgeryGastroenterologyOrthopaedics – includes fracture surgeriesGenito-UrologyEndocrinology ENT.100% Cashless facility

  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. Diagnostics • Investigations like X-ray, Blood tests, Urine tests Ultrasound CT, MRI, etc covered • Can be done at Network Hospitals at special discounted rates

  10. Cashless Service at Network Hospitals • ID cards will be issued to every member enrolled. • Member produces card at Network hospitals to avail of services. • Hospital seeks pre-authorization from ZS for giving cashless service or any planned procedure • Based on eligibility, ZS gives authorization to Hospitals to start treatment. • Member to undergo the required treatment • Member will sign on claim form, at discharge • He pays only for exclusions under the scheme.

  11. Premium • For 4 lives-Rs. 260/year Premium Collection - One time Upfront payment

  12. 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 Benefits

  13. Exclusions • Prosthesis and Implants including Valves, Grafts Mesh, Stents, Nails, Screws, Spectacles, Hearing Aids • Transplants • Cosmetic Surgery • Malignancies – Chemotherapy, • Angioplasty • Autoimmune diseases • Vaccination • Dental surgeries • Dialysis • Vitamins and Tonic • Ambulance Services • Food and other Non Medical expenses • Any other expenditure, which are not related to illness/hospitalization

  14. Implementing Agency (Zilla Samakhaya will act as TPA) • 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 • Maintaining member database • Arrange for cashless treatment for the beneficiary in • Network Hospital by issuing pre-authorization • Claims Processing and settlement • Maintenance of accounts • Generation of periodic report on utilization (statistics) • Administer the scheme, avoiding misuse and fraud • Appoint required manpower to monitor, manage and maintain the scheme.

  15. 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

  16. Hospital Accreditation Process Flow START 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 STOP

  17. Enrollment • Village Organization will take the responsibility of Enrollment • 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 • 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. • As soon as members get the ID card they can avail the treatment at NWH

  18. START Enrollment Filled by Member Collection of Fee and photograph taken Attestation by VO Representative. Issuance of Receipt to member VO Representatives deposits the Fee to MS or ZS Bank account VO Reps forwards enrollment forms to ZS Data from Enrollment form entered into software Generation of Photo ID Cards and covering letters Dispatch of ID Cards to VO Reps Distribution of ID to members by VO Reps STOP

  19. Free OPD Consultation Investigation Special rates Availing the Treatment START Beneficiary goes to Network hospital with ID Card, Receipt Admission for Medical treatment Admission for Surgery Intimation to ZS by NWH Patient pays only 10% of co-payment Pre-Authorization- from ZS CASHLESS Hospitalization Member signs on the Claim Form Discharge

  20. 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

  21. START Complicated/General/ Exceptions Preauthorization Flowchart Receive of Intimation from Hospital A-Eligibility Verification ID card, Receipt, Residential Proof B-Medical verification No Letter of Rejection to Hospital Yes Generation of Pre-Authorization Serial No. Data entry into Software Complicated cases Sent to VO Rep for verification Exceptions General Sent to Hospital for supporting reports verification Eligibility Medical Officer checks and fixes rate Eligible NO Authorization letter to hospital Letter of Rejection to Hospital STOP

  22. Claim The Claim Form from the Hospital should be accompanied by • Photocopy of the I.D. Card • Original claim form with the signature of the beneficiary. • Final split – up bill – with the signature of the beneficiary raised in the name of “ZS.” • Original authorization issued by ZS • Original discharge summary • Operation Note from treating Doctor (Incase of surgery) • Original Investigation and Lab Reports • List of consumables prescribed

  23. Claims Flowchart Receipt of claims From NWH Document verification Incomplete Communication To Hospital Complete Claim ID Generation Medical Scrutiny and Claims Processing Claim pending for supporting Documents Approved Claims Communication To Hospital Letter Of Settlement To the Bank By ZS Collection of DD Dispatch o hospital Outward

  24. Process of Reimbursement to NWH • Claims checked for required documents • Medical scrutiny of the Claim by ZS medical officers • DDs dispatched to the Hospitals

  25. Controls and quality checks • 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 • ZS coordinators (Case Managers)

  26. Obligations as a NWH • All Network Hospitals (NWH) shall display a board with “Scheme Name” in Telugu prominently at the reception. • 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 • The package rates mentioned are all exclusive of the implants and theprosthesis. • The beneficiaries under the Scheme will be entitled only for General Ward Admission

  27. OPD Record

  28. Surgery Statistics Report Date:

  29. OPD Statistics Weekly ReportName of the Hospital PlaceStatistics From: To:

  30. IPD Weekly Statistics ReportName of the Hospital : District :- Surgery Statistics From: To: No. of surgeries/Medical Admissions performed for the current week :-

  31. Details of Investigations

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