The state government is plugging holes in Swasthya Sathi payouts, said officials.
“The analysis and audit system for the scheme has been strengthened to prevent misuse. We have also restructured the surveillance teams,” said Narayan Swaroop Nigam, state health secretary.
In the past few weeks, several anomalies were detected. In course of the surveillance, doctors and private healthcare institutes have been identified who have been either over-treating patients or raising false bills.
The process would be evolved further to streamline the payment system which may include omitting some basic treatments like fractures of limbs and hernia surgeries from the scheme.
According to a member of the surveillance team, they recently found out that two private healthcare institutes in different parts of the state had raised claims for surgeries performed by the same doctor.
“It is not possible for a doctor to be physically present at two geographical locations at the same time,” said the official.
In another case, a private facility had raised a bill for a doctor of a state-run hospital, officially on leave and out of station, but who had apparently conducted a procedure during the period, said the official.
“We are also finding cases where the doctor and the private hospital or nursing home are shifting to aggressive treatment even though conservative medical management was possible,” said the official.
He said the health department was imposing fines or asking the healthcare facilities to return the inflated amount.
According to health officials, at a recent meeting, many medical superintendents of government hospitals complained that simple procedures and treatments like that for treating limb fractures or hernia have almost stopped at these hospitals because patients and a section of doctors are interested to get it done at private facilities under the Swasthya Sathi scheme.
“We are planning to omit such small surgeries and treatments from the scheme to make optimum use of government facilities,” said an official.
Health officials said global consultancy firm E&Y (formerly Ernst & Young) had recommended strengthening the audit system.
The Telegraph had reported earlier that the consultancy firm was engaged by the state to review the scheme which has now been converted into assurance scheme. The state government is now settling the claims under the scheme directly instead of making payments through insurance firms.
“Swasthya Sathi scheme is on a learning curve and as a part of that, changes are being made at various levels,” said an official.
Private hospitals said they were happy about the assurance scheme.
“We had to follow up with the insurance companies as well as the government. Now, it is only the government,” said an official of a private hospital.
“The issue of low rates still continues and unless it is resolved such anomalies like false and inflated bills would continue,” he said.
