Even AS the Rajiv Gandhi Jeevandayee Arogya Yojna (RGJAY) is faring well in almost all parts of the state, its implementation in the city’s civic-run hospitals has been an issue. As many as 2,530 claims are pending in the city’s civic hospitals of which 93 per cent (2,362) claims are pending in the three tertiary hospitals — KEM, Sion and Nair — since the scheme was launched on July 2, 2012.
The situation in the peripheral hospitals is better, with 168 claims pending. The issue, RGJAY and BMC officials agree, is at multiple levels, with lack of dedicated staff at the helm of the scheme.
A proposal has been sent to Municipal Commissioner Sitaram Kunte to allot dedicated staff for processing the documentation work under the scheme.
Additional Municipal Commissioner Sanjay Deshmukh said, “In civic hospitals, the doctors who are operating under RGJAY have to do an additional job of preparing all documents for claims reimbursement. As they are over-worked, clerical errors are getting frequent due to which our claims get rejected.”
Piyush Singh, COO of RGJAY, said, “Several claims are rejected or returned because of lack of documentary evidence from hospitals. The third party authority will not forward claims to the insurance company for payment until all necessary documents are submitted.”
The working of RGJAY involves a Memorandum of Understanding (MoU) between three parties — the hospital, third party authority (TPA) and National Insurance Corporation (NIC). Once a patient is admitted under the scheme, a pre-authorisation consent for operation is required.
After the surgery, the hospital has to submit documents — such as pictures of patients and surgery, reports of tests, diagnostic reports — to the TPA which scrutinises them.
“The approved claim is forwarded to NIC that has to clear payment within 15 days of receipt. There is little backlog from their end,” said Singh.
The state has authorised MDIndia, Mediasist and Paramount as the three TPAs for the 373 hospitals empaneled under the scheme.
Of the 2,530 claims pending, 1,067 claims are at the hospital level with maximum claims in KEM (628). There are 369 claims pending with TPA and 425 at NIC level.
The issue had led to closure of several procedures in KEM and Nair hospital recently. Dr R N Bharmal, dean at Nair, said, “CABG procedures were stopped for a short duration as due to rejection of claims the hospital could not reimburse vendors for the medical supply. Now I have put extra staffers to work on documents required for claims. Over 60 per cent claims in cardiac procedures have been cleared.”
Dr Shubhangi Parkar, dean in-charge at KEM, said, “We realised the issue late. We have asked for 10 staffers for tertiary hospitals who will solely work on processing payment.”
The BMC also internally conducted several meeting with vendors to start the medical supply.
Dr Avinash Supe, dean of Sion hospital, said, “We have assigned two officers to do documentation work under RGJAY. This has reduced workload of doctors .” Sion hospital has only 61 claims pending at its level as opposed to 628 pending with KEM and 331 at Nair hospital.
Singh from RGJAY said, “Initially, BMC asked us to provide staff. But our scheme is to only provide free surgeries to poor people.”
A doctor from KEM hospital said, “Administrative work of RGJAY increases work load. In private hospitals, claims are handled by administrative staff.”