Fraud Investigation and Medical Audit Manual  |  a

FRAUD INVESTIGATION AND

MEDICAL AUDIT MANUAL
Ayushman Bharat
Pradhan Mantri Jan Arogya Yojana (PM-JAY)

NATIONAL HEALTH AGENCY

DECEMBER 2018
 FOR
REWOR
RD
Nationnal Health A
Agency
Miinistry of He
ealth and F
Family Welfa
fare
Goveernment of India

Ayyushman Bharat – Pradhan Mantrri Jan Arogy ya Yojana (P PM-JAY) en ndeavors to offer secon ndary and
te
ertiary health
h coverage ofo Rs. 5,00,0000 to more e than 10 cro ore beneficiary families, accounting
g for more
th
han 40 percent of Ind dia’s populaation at em mpaneled ho ospitals. Th
his unprecedented effo ort of the
G
Government of o India is lik mpact on the poor and vu
kely to have a significant positive im ulnerable po
opulation’s
acccess to high quality heaalthcare.

G
Global experiience shows s that integrrity violations
s in health iinsurance programs are e high. Frauud in such
prrograms nott only resultt in financia al losses butt have a mu uch greaterr impact on people’s he ealth. The
ulltimate respo onsibility to effectively prevent,
p dete State Health Agencies
ect, and detter fraud liess with the S
(S
SHA). Strong anti-fraud efforts are important not only fro om the persspective of rreducing the e adverse
im
mpact on sch heme financ ces and for safeguarding
s g beneficiaryy health butt also to mitiigate any re
eputational
rissk faced by the SHA, sta ate and the scheme resulting from ffraud. Hence e, SHA’s antti-fraud efforrts are key
fo
or ensuring effective
e impplementationn of PM-JAY and it is crittical that a “zzero tolerance” approacch to fraud
be e internalize
ed and perme eate all aspe
ects of mana agement of tthe scheme..

W
With this spiriit, the Nation
nal Health Agency
A has previously
p d eveloped An nti-Fraud Gu uidelines, re
eleased by
Hon’ble Healtth Minister on o 29th August 2018 lay ying down th he overall viision and ro oadmap for ccombating
fra
aud and abuse that cou uld be perpeetrated unde
er PM-JAY. To bring un niformity andd consistenccy in anti-
fra
aud actions and build capacity
c in SHAs,
S NHAA is proud to o share the Fraud Invesstigation and Medical
Audit Manual for PM-JAY Y. We sincereely hope tha
at state goveernments pa n PM-JAY will use this
articipating in
m
manual to streengthen the management of anti-fra aud activitiess in their respective statees.

Dr. Indu Bhushan

Chief Exe
ecutive Offic
cer
National Health Agenncy

Fraud Investigation and Medical Audit Manual  |  iii

Table of Contents
Fraud and Abuse Control under PM-JAY........................................................................................................... 1

Objective of the Manual......................................................................................................................................... 2

Minimum Requirements for Audits and Investigations................................................................................ 2

Process Flow and Standard Formats............................................................................................................... 3

1. Beneficiary Verification Audits............................................................................................................................ 3

A. Process flow for audit of cases from CSC or Hospitals.............................................................................. 4
B. Process flow for audit of triggered cases after claims................................................................................ 5

2. Utilization Audits.................................................................................................................................................. 6
A. Pre-Authorization Stage.................................................................................................................................. 6
B. During Hospitalization stage (live audits, before discharge)...................................................................... 7
C. Claims Stage (post-facto audits, after discharge)........................................................................................ 8

3. Mortality Audits.................................................................................................................................................... 9
Process flow for Mortality Audit......................................................................................................................... 9

4. Claims Audits........................................................................................................................................................ 10
Process Flow........................................................................................................................................................ 10

Code of Conduct for Staff handling Field Investigation and Medical Audit . ......................... 11

Monthly Reports and MIS to be Submitted to NHA . ............................................................................... 11

ANNEXURE 1: beneficiary audit form ............................................................................................................ 13

ANNEXURE 2: Medical Audit Form . .................................................................................................................. 16

ANNEXURE 3: Field Investigation Format..................................................................................................... 19

ANNEXURE 4: ON-SITE INVESTIGATION FORM . ................................................................................................... 22

ANNEXURE 5: MORTALITY AUDIT FORM ............................................................................................................... 30

ANNEXURE 6: CLAIM AUDIT FORM . ....................................................................................................................... 42

ANNEXURE 7: Reporting Format ...................................................................................................................... 44

ANNEXURE 8: HANDLING DIFFICULT SITUATIONS . ............................................................................................. 50

ANNEXURE 9: TRIGGER POINTS . ........................................................................................................................... 52

Fraud Investigation and Medical Audit Manual  |  v

F
Fraud and
a Abbuse Control
C l under PM-J
JAY
Thhe main objective of PM M-JAY is to provide the poor and vvulnerable po opulation off the countryy with free
quuality healthcare service
es in public and private hospitals. T
The success of PM-JAY assumes th he smooth
annd effective coordination
n between different
d keholders wiith a view to
stak o providing qquality seconndary and
te
ertiary care to
t the pooreest of the po
oor and vulnnerable (as identified byy Socio Ecoonomic Castte Census
daata 2011) ata no cost too them. The e also expos ses a risk oof leakages in the formm of fraud a and abuse
prractices at each
e level.

Frraud under the

t PM-JAY Y shall mean and include
e any intentio
onal deceptiion, manipullation of factts and / or
doocuments orr misreprese entation mad
de by a person or organ ization with the knowled dge that the deception
co
ould result in unauthorized financ cial or othe
er benefit too herself/himmself or soome other p person or
orrganization. It includes any
a act that may
m constitu ute fraud und
der any app plicable law in India.

PM-JAY is go overned based on a zero o-tolerance approach to

o any kind off fraud and a
aims at deve
eloping an
annti-fraud culture that pe
ermeates all aspects off the scheme’s governa ance. The approach to anti-fraud
effforts shall be based on five fo ounding priinciples: Trransparencyy, Accounta ability, Resp
ponsibility,
In
ndependence e, and Reas sonability.

Thhe NHA has s taken seveeral steps to ensure dete ection, preveention, dete
errence and spreading a awareness
off fraudulent practices at all levels. These
T include e developme ent of the Anti-Fraud Gu uidelines, se
etting up a
ro
obust IT systtem with a proactive
p andd effective frraud control and detectio on capabilityy and conducting anti-
aud capacitty building trainings for State Health Agenciess (SHA). Th
fra he success of these iniitiatives is
deependent on n the effectiiveness and d robustness s of the inveestigation and audit me echanism att the SHA
le
evel to inves stigate fraud, carry out audits
a and necessary
n acction once tthe suspect cases are fflagged by
annti-fraud triggers or by processing
p te
eams.

Table 1: Fraud Management ap

pproaches at
a different stages of implementa
ation

Frau
ud managem
ment Sttages of im
mplementatio
on
approaches
a s
x Benneficiary ide
entification an
nd verificatio
on
Preventio
on x Pro
ovider empa nelment
x Pre
e-authorisati on
x Cla
aims manage ement
Detection
n x Datta analytics
x Fie
eld and Medi cal Audits
x Contract mana agement
Deterrenc
ce and Reco
overies x Enfforcement off contractua al provisions
x Stringent actionns against thhe offenderss

Fraud Investigation and Medical Audit Manual  |  1

 O
Objectiive of the
t Maanual
Thhis Investigation manual has been n developed d by NHA iin order to assist SHA As in develo oping and
im
mplementing robust and d consistent anti-fraud in
nvestigation and audit ssystems to d detect, prevvent, deter
annd recover any fraud losses unde er PM-JAY in different stages – ffrom beneficiary identiffication to
tra ation/Claims submission and payme
ansaction/Pre-authoriza ent. It is crittical that all agencies innvolved in
PMJAY imple ementation adopt stand ces, formatss for data ccapture for integration with core
dard practic
Trransaction Managemen
M t System annd for meaninngful reporting and anallysis purpose. The SHA As are also
re
equired to su
ubmit monthly reports on
n anti-fraud measures
m with results achieved therreof.
w

M
Minimu
um Req
quirem
ments for
f Aud
dits an
nd Inve
estigattions
Thhe Anti-Frau
ud Guideline
es developed
d by NHA sp
pecifies the mminimum sa amples for audits to be cconducted
byy the SHA under AB-PM MJAY. The sa
ame are outtlined in Tab
ble 2 below:

Table 2: Recommend
R ded minimu
um sample for audits

Audit Type Sam

mple for Ins
surer / Sam
mple for S
SHA Audit
TPA Audit
2% direct audits +
Medical aud
dit 5% of total cases ho
ospitalised 2% of audits done by tthe
Insurer / T
TPA /ISA
Death auditt 100% 100%
Each em mpanelled ho
ospital at Each empanelled hospital at leastt twice
Hospital aud
dit
least twice each yea
ar a year
5% direct audits +
Beneficiary audit (during
g
10% of total
t cases hospitalised
h 10% of audits done byy the
hospitalisatiion)
Insurer/TPPA /ISA
Beneficiary audit 5% direct audits +
arge –
(post discha 10% of audits done byy the
10% of total
t cases hospitalised
h
through Insurer/TPPA /ISA
telephone)
Beneficiary audit (post 2% direct audits +
discharge – through 5% total cases hosp
pitalised 2% of audits done by tthe
home visit) Insurer /TPPA /ISA
2% of audits done by tthe
10% of total
t pre- Insurer / T
TPA /ISA for
Pre-authoris
sation audit authorisaations acros
ss disease Insurance mode)
specialties 10% of audits done byy the TPA
/ISA (for A
Assurance mmode)

2  |  Fraud Investigation and Medical Audit Manual

 3% of audits done by tthe
Claims audiit (approved Insurer /TPPA /ISA for IInsurance m
mode)
10% of total
t claims 10% of audits done byy the TPA
claims)
/ISA (for A
Assurance mmode)

Claims audiit (rejected - 100%

claims)

In
n addition, th
he model te
ender docum
ments specify minimum
m requiremen
nts for investigation of cases by
In
nsurance com mpany/ISA.

It is possible that SHAs may

m like to carry
c out auddit and invesstigation of ssuspect tran
nsactions wh
hich would
allso help fulfil/meet the above require
ements or may
m carry outt the same a additionally.

Th
he Claims Review
R Com
mmittee and Mortality & Morbidity Re eview Comm mittees set u
up at State llevel shall
be
e forwarded d all the se
erious/repeatt fraudulentt transaction aims/mortalitty cases for audit in
ns/reject cla
ad
ddition to be
elow mention
ned processees.

P
Proces
ss Flow
w and Standa
S ard Forrmats
Thhe following
g sections prrovide overv view of auditt and investtigation proccesses along g with releva ant format
fo
or each type. As per pro ovisions of Anti-fraud
A Gu uidelines, SH
HAs are requ uired to recrruit trained m
manpower
fo
or investigatiion and med dical audit, however
h undder certain ccircumstancces, SHAs m may utilize services of
sp
pecialized external
e agencies for ca arrying out investigation
n and auditts. The Stan ndard proce esses and
fo
ormats applyy to all agencies carrying g out the tas
sk of investi gation and aaudits underr PMJAY. SHAs may,
hoowever, include addition nal checks, provisions, data
d e and analyssis as requirred for their particular
capture
Sttate without diluting the provisions la
aid down under this man nual.

1.. Beneficia
ary Verificattion Audits

The proba
able frauds at
a the level of n of benefici ary can inclu
o verification ude:

x Issuannce of e-cardd (golden record) to a no

on-eligible p
person
ation of services under th
x Utiliza he scheme byb someone impersonatting to be the
e beneficiaryy
x Ghostt Utilization – Claim su ubmitted by a provider without actual hospitalization of a
an entitled
benefiiciary

Beneficiarry audits for issuance off golden card

d to a non-elligible perso
on

A membe er of entitled family unde

er PM-JAY can get a gollden card (e
e-card) gene
erated after p
process of
verification either at a CSC or an empanelled hospital

Fraud Investigation and Medical Audit Manual  |  3

 ess flow for audit of cases from CSC or Hosp
A. Proce pitals

Benefficiary audits
s will also be
e conducted on random
m basis or poost admissioon in cases w
where the
anti-fra
aud triggers
s flag the cllaim as sus
spicious – a
at pre-auth sstage, pre-d
discharge sttage, post
dischaarge or post payment.

4  |  Fraud Investigation and Medical Audit Manual

B. Proce ggered cases after cla
ess flow for audit of trig aims

Fraud Investigation and Medical Audit Manual  |  5

 2.. Utilization
n Audits

Authorization Stage
A. Pre-A

t empaneled health ccare providerr sends pre--authorizatio

e - authorization stage, the
At pre on request
to SHAA/ Insurer/ISSA. Fraud trriggers deveeloped by N NHA/SHA wo ould flag the
e pre-auth re equest as
‘suspic
cious’ if it meets
m certain pre-define
ed criteria/triiggers. The pre-auth ap pproval teamm reviews
the ca
ase and may y choose to request add ditional docuuments or co onduct a me edical audit ((Annexure
2) as needed, req quests for ad
dditional doccuments. Aftter reviewingg the docum ment, case m may either
be appproved denie ed or referre
ed for investiigation.

Pre-Auth req
quest receivedd by SHA/IC/IISA

Fraud
F Triggerss flag pre-autth as ‘suspicio
ous’

Pre
e-auth team validates
v susppicion – Desk Audit

Desk Audit confirms

c claim
m as suspicio
ous

Addition
nal documentts requested

Do
ocuments Revviewed

Case approved / denie

ed Case ssuspicious

Send fo
or further
Investtigations

6  |  Fraud Investigation and Medical Audit Manual

B. During Hospitaliz zation stage e (live auditts, before d
discharge)
Duringg hospitaliza
ation stage, system trigggered casess, or the cases directed by pre-auth team are
or field investigation (An
sent fo nnexure 3). If fraud is cconfirmed be
efore the disscharge, the
en case is
sent fo
or action/dennial of pre-authorization and if confi rmed as non
n-fraud, the case is proccessed on
merits
s as in norma al course.

System geenerated Case ddirected by th

he
triggered case Pree-auth team

Case
e sent for field investigatioon

Yes
Fraud
F confirm
med before Casee sent for
discharge aaction

No

Case is
processe
ed on
merits

Fraud Investigation and Medical Audit Manual  |  7

 C. Claimms Stage (po ost-facto au udits, after discharge)
d
In casse of post-discharge or at the time e of claim ad djudication/ payment off the claim, the fraud
triggerrs will highliight certain cases as “s suspect” wh hich would n need to be investigated d/ audited.
Thesee cases are first
f revieweed by the Inssurance Com mpany/ ISA ffor prima-faccie/ fact veriification to
ensuree that any apparent
a false positivess are filteredd out. If the case rema ains suspectt post first
level scrutiny,
s then the case will
w be sent for field inve estigation orr medical au udit dependiing on the
naturee of fraud triggger and the e evidence needed
n for vverification ((refer annexx 3,4). The ccases may
also be
b triggered based on re eview by Sta ate Claims R Review Com mmittee and Mortality & Morbidity
Review w Committe ee in the normal
n course of their functions. If fraud is confirmed after field
investigation, thenn its report and findings are
a shared b by Medical O Officer for the final decission.

Triiggered casess

Fact verifiication by dessk audit

Yees
Fraud Case sent for
Suspect med
dical audit

Yes

Fie
eld Investigattion or on-sitee investigatio
on

SSend Inve
estigation Needs
N further In
nvestigation confirms Case
reeports Confiirms Fraud Medical
M Auditt case as non
n fraud closed
and
finddings to Yees
medical Medical Audit
offiicer for
ffinal No
deecision C
Case
Frau
ud Confirmedd closed

Yes

Case sent
s for actio n

8  |  Fraud Investigation and Medical Audit Manual

 As reg
gards cases s triggered/m marked for medical
m aud
dit, the Med dical Auditorr may also cconduct a
desk audit
a or field
d audit depe ending on th he facts to be verified tto confirm tthe suspicion and will
commmunicate his final finding gs to the Medical officeer for his fin nal decision. In some ccases, the
claim may be sen nt for field investigation
n followed bby a medical audit team m to review additional
docummentation whhich may hav ve been collected duringg the first sta
age.

In both cases, the t Medicall officer willl review th

he observattions and ffindings of the Field
Investtigator, on-site investiga
ation team and
a hile taking a final decisio
Medical Auditor wh on on the
matterr.

3.. Mortality Audits

As per Annti-Fraud Guidelines, 100 0% mortality

y claims wouuld be referre
ed for auditss. The hospittals would
be require
ed to provide
e all the rele
evant informaation as spe
ecified in Annexure 5 an nd the same e would be
eal cause of death and ttake necessary action
reviewed and verified by the audiit team to identify the re
in case of
o death due e to neglige ence. All cas
ses of Morttality must b be put up to o State Morrtality and
Morbidity Committee for
f final revie ew and deciision.

Process flow for Mo

ortality Aud
dit

x Eveery death occcurring in th

he network hospital
h sho uld be intimated to SHA A within 48 h
hours with
a brief death su
ummary
x Eacch network hospital to constitute a Mortality Audit comm mittee and this commiittee shall
review/examine e the cause e of death and the repo ort shall be submitted too SHA at th he time of
claiims submisssion
x Sta
ate Mortality and Morbid dity Committtee to screeen and cond duct detailed
d mortality a
audit of all
deaath cases
x Final decision would
w be takken by State
e Mortality an
nd Morbidityy Committee.

Fraud Investigation and Medical Audit Manual  |  9

 4.. Claims Audits
A

There may be some fraud

f cases which may initially go u
undetected aand incorrecttly approvedd and paid
by the Ins
surance com
mpany/TPA/ ISA/
I SHA. To
T identify su uch claims, iit becomes iimportant that audit of
randomly selected caases or trigg
gered cases
s is done o on a periodic basis. Th he reporting format is
mentionedd as Annexuure 6.

x Claim Review com mmittee shalll Review 100 percent cl aims that arre rejected bby the Insureer / TPA /
ISA / SHA
S and appealed by th he provider;
x Rando omly review / audit at lea
ast 2 percen
nt of the pre--authorizatio
ons and 3 pe
ercent of the claims of
each provider
p eac
ch quarter.

Process Flow
x Triggeered cases or
o randomly selected
s proved/paid cases are a
app assigned to tthe audit teaam
x Medic cal doctor of the audit tea
am validatess the docume ents submittted by the ho ospitals duriing claims
submission and sh hares reportt with finding
gs.
x SHA takes a final decision based on the report
r finding
gs and takess disciplinaryy action whe
erever
require
ed.

10  |  Fraud Investigation and Medical Audit Manual

C
Code of
o Cond duct fo
or Stafff hand
dling Field
In
nvestig
gation and Medica
M al Auditt
x To mainntain highestt standards of
o professionnal conduct and integrityy in all situattions
x To carry
y out investigation/audit work withou ut disruptingg or interfering in ‘treatm
ment of bene eficiary’ in
any mannner whatsooever
x To mainntain confideentiality of health
h data/information collected during the co ourse of invvestigation
and aud mit the same to competen
dit and subm nt authority
x To alwaays carry auuthorization/permission from compe etent authorrity to condu uct investiga
ation/audit
and prodduce the samme to hospittal/beneficiary as the ca se may be
x To alwa
ays maintain dignity of pa ocial norms during bene
atient and so eficiary intervviews
x Not to give
g impresssion of extraaneous auth hority of anyy kind while acting on b behalf of SHHA or any
agency working for SHA under PM-JAY

M
Monthly Repo
orts an
nd MIS
S to be Subm
mitted tto NHA
A
Thhe SHAs are e required to
o submit monthly report by 7th of evvery month to o NHA listing
g the measu ures taken
to
o control frau
ud, data ana
alysis, cases
s investigated d and audite ed and the rresults there
eof and punittive action
ta
aken againstt fraudulent parties, notices, issued d, recoveriess made etc. This would enable NHA A to track
th
he progress of the state es, draw coomparative analysis,
a proovide furthe
er support and feedback, to take
acction as neeed be. Refeer to Annexuure 7 for the e format of the report. It is suggested to the SHA that
m
monthly reporrt format to be
b collected at district le
evel for their own referen
nce and deta ailed analysis.

Fraud Investigation and Medical Audit Manual  |  11

 An
nneexurre 1::
Ben
B efic
ciary udit Forrm
y Au
AY
YUSHMAAN BHAARAT –
PRADHAN MANTRI
M JAN AR
ROGYA YYOJANA
A
 Annexure 1

A. Patien
nt Information

1. PM
M-JAY FAMIILY ID: ____ __________________
2. Na
ame:
3. Fa
ather’s or Hu
usband’s nam
me:
4. Ad
ddress:
Dis
strict: State: P
Pin Code:
5. Co
ontact No.
6. Me
embers regis stered:

PM-JAY ID
S
S. No. Name Gender Ag
ge Re
elationship
number

1.

2.

3.

4.

5.

6.

B. Generral Informattion

1. Where was the

e E card ma
ade?

2. If hospital,
h was
s the benefic
ciary charge
ed any mone
ey for the E ccard? If yes,, how much?
?

3. Ha
as s/he availled services under PM-J
JAY? If yes --proceed furrther

4. In which hospiital did s/he utilize the se

ervices?

5. What symptom
ms were the patient exhiibiting when he/she visitted the hosp
pital?

6. When did s/he

e get admitte
ed?

7. When did s/he

e get discharrged?

14  |  Fraud Investigation and Medical Audit Manual

 Annexure 1

8. Fo
or how many
y days was s/he
s hospitallized?

9. Was s/he prov

vided free food?

10. What was the treatment given?

11. If any
a surgery,, is there a scar
s on the body,
b which could help in
n verification
n of the surg
gery. (If
ye
es, take phottograph of th
he same)

(4 -11: match the informa

ation provided by the ben
neficiary with
h the one recorded in the TMS)

C. Match
h the photo of the bene
eficiary bein
ng interview
wed with the
e one subm
mitted in TM
MS

D. Any other
o remark
k or observ
vation:

mmendation of the Auditor:

E. Recom

nd Signaturre of the Auditor with Date:

Name an D

Fraud Investigation and Medical Audit Manual  |  15

 Annexure 2:
Medical Audit Form
Ayushman Bharat –
Pradhan Mantri Jan Arogya Yojana
 Modified Medial Audit Qs Options for answer Remarks
selection

S. No. Criteria
1 Pertaining to Clinical Information (Patient history and evidence of
physical examination is evident)
a. Is the chief complaint recorded? Pl look for package specific complaints Yes/ No

b. Is History of present illness (HOPI) mentioned? Should have Onset, Yes/ No

duration and progress of relevant symptoms/ signs
c. Are relevant personal history of beneficiary noted (positive or negative)? Yes/ No
Viz, abuse of tobacco/ alcohol/ intoxicating substances consumption?
(the next Q get enabled if answer to this Q is YES)
d. Is the above positive history relevant to having caused the package Yes/ No
diagnosis?
e. Does this above history (whether captured or not) makes the package Yes/ No
NOT applicable as per exclusion policy?
f. Is a report on relevant physical examination available? Pl look for Yes/ No
package specific findings
g. Is general examination and other systems (CVS, CNS, AS, RS) done and Yes/ No
findings reported? Pl look for package specific data
2 Progress notes from admission to discharge
a. Are admission notes and detailed findings at admission notes available? Yes/ No

b. Are daily recorded progress reports available? Pl look for package Yes/ No
specific sequential information, which should have been captured.
c. Is each progress report signed and dated? Yes/ No
d. Are reports of patient’s progress filed chronologically? Yes/ No
e. Are Specific instructions to discharge the patient and line of treatment Yes/ No
after discharge captured in ICP's?
f. Is a Discharge summary available? Yes/ No
g. Does the discharge summary capture all details of presenting features, Yes/ No
investigations, line of treatment given during stay line of treatment
advised at discharge and (Select <No> if investigations and all treatment
details, missing as follow up will be not be rational)

h. Are instructions to follow up explicitly given? Yes/ No

3 Pathology/ laboratory/ Radiology reports Scrutiny (only one of the 2
sets a-d or e-f have to be answered )
a. If it is a Medical / emergency surgery Package, Are pathology/ Yes/ NA
laboratory reports available
b. Are reports relevant to package, the diagnosis and treatment given? Yes/ No
Package specific list
c. If it is a Medical / emergency surgery package, Are radiology reports Yes/ NA
available?
d. Are reports relevant to package, the diagnosis and treatment given? Yes/ No
Package specific list
e. If it is a planned surgery package, Are justifying lab/ radiology / Yes/ NA
Frozen section/ FNAC/ biopsy reports available?
f. Are reports relevant to package diagnosis, the diagnosis and treatment Yes/ No
given? Package specific list
4 Is an operation report available? (Only for surgical Packages) Yes/ No

This Surgery Is more likely to be Planned surgery/ emergency

surgery/ could be either emergency or planned surgery.

Is Pre-op Profile Available (Relevant to Package, Age & Co- Yes/ No

morbidities)

Fraud Investigation and Medical Audit Manual  |  17

 4A. Planned surgery- Yes/ NA
a. Does the report include Pre and post-operative diagnosis (Both should be Yes/ No
same)?
b. Is the correct package blocked? Yes/ No
c. Are the justifications of arriving at the diagnosis rational? Package Yes/ No
Specific list
d. Is the date and time of procedure mentioned? Yes/ No
e. Is the surgeon who has operated same as the name given while blocking Yes/ No
the package?
f. Is the surgeon’s signature available on records? Yes/ No
4B. Emergency surgery Yes/ NA
g. Does the report include pre-operative diagnosis? Yes/ No
h. Does the report include post-operative diagnosis? Yes/ No
i. Are the above two similar? (Need not be exactly same) Yes/ No
j. Was the decision to operate rational w.r.t clinical features? Yes/ No
k. Are the justifications of arriving at the diagnosis specified? Yes/ No
l. Is the date and time of procedure mentioned? Yes/ No
m. Is the surgeon who has operated same as the name given while blocking Yes/ No
the package?
n. Is the surgeon’s signature available on records? Yes/ No
5 Documentation scrutiny
a. Do all entries in medical records contain signatures? Yes/ No
b. Are all entries dated? Yes/ No
c. Are times of treatment noted? Yes/ No
d. Are signed consents for treatment available? Yes/ No
e. Is patient identification recorded on all pages? Yes/ No
f. Are all nursing notes signed and dated? Yes/ No
6 Does the claim fall under any clause of Schedule 2 - Exclusions to policy Yes/ No

Auditor's Conclusion Red/ Amber/ Green

Space for adding observations basis which this conclusion is arrived at

18  |  Fraud Investigation and Medical Audit Manual

 Annexure 3:
Field Investigation Format
Ayushman Bharat –
Pradhan Mantri Jan Arogya Yojana
 Annexure 3 - Field Investigation Format
Reason for field validation Routine claims review medical audit request
A. Patient/Claims Details
Name of Patient Gender Relation
PM-JAY card no. or State Specific scheme No.
Address

Name of Hospital -
Address of Hospital -

Hospital ID (if available)

B. Facility inspection: Need to match against the details submitted at the time of empanelment and claim submission
Hospital Existence Yes No
Response from Hospital Co-operative Non Co-operative Indifferent
Is Hospital Registered DGHS Yes No Reg. No.
No of Beds
No of OT
Pathology/ Diagnostics Inhouse Out sourced Not Available
Type of Hopsital Public Private
Name of Treating Doctor
Speciality
Dr Registration Number
Contact Number of Treating Doctor
Date and time of Hospital Admission as per hospital file
Date and time of Hospital Discharge as per hospital file
Type of Treatment Surgical Conservative
If MLC/FIR, not available then specify the reasons
Diagnosis:
Any other remark or observation:

C. Documents Review: Observations noticed for each parameter need to be entered in terms of completeness, errors, overwriting or any discrepancies noticed
Is IPD Collected Yes No
If yes, please upload
If no specify the reason
Indoor Register Entry Verified (upload) Yes No
Hospital Lab Register Verified (upload) Yes No
Treating Doctor Certificate Verified (upload) Yes No
All Medical Histroy of patient documented (upload) Yes No
Pateint clinical information is documented (upload) Yes No
Is there any previous hospitalization of same patient at the same hospital Yes No
Past history details documented Yes No
Complete Medication list on chart and nursing chart (upload) Yes No
Findings and follow ups are documented (upload) Yes No
Deatiled progress notes reflecting evaluation of each visit, reason for visit is documented as relevant Yes No
Any other remark or observation:

D. Patient profile
Patient Photograph collected with ID card (upload) Yes No
Patient Id's proof Collected (upload) Yes No
Any other remark or observation:

E. Patient/Attendent interview in the hospital

What symptoms were the patient exhibiting when he/she visited the hospital?
When did the patient got admitted?
Is the patient admitted since then?
Was the patient informed about the name and value of the package which was blocked by the hospital
What diagnostic tests (if any) were performed on the patient?
Was he/she operated upon, if yes, is there a scar on the body, which could help in verification of the surgery.
(If yes, take photograph of the same)
Has any money been charged so far? If yes, how much?

20  |  Fraud Investigation and Medical Audit Manual

Any other remark or observation:

F. Home Visit: Patient/Attendent interview after discharge

Has s/he availed services under PM-JAY? If yes -proceed further.
In which hospital did s/he utilize the services?
What symptoms were the patient exhibiting when he/she visited the hospital?
When did s/he get admitted?
When did s/he get discharged?
For how many days was s/he hospitalized?
Was s/he provided free food and travel allowance?
Was the patient informed about the name and value of the package which was blocked by the hospital
Was the patient given a discharge summary? Does the patient still possess that discharge summary? If yes
physically verify the same
Was post-hospitalization medication provided to the patient?
Was any money asked by the hospital at any point of time. If yes, then how much and for what purpose?
Was patient or the attendant asked to purchase any the medicine or carry on any of the diagnostic test at
their own cost?
Does the patient have any receipt for the same? (If yes, take photograph of the same)
What was the treatment given?
If any surgery, is there a scar on the body, which could help in verification of the surgery. (If yes, take
photograph of the same)

Any other remark or observation:

Comment of Investigator

Final Opinion of the Investigator Genuine

Fraud
Abuse

Name of Investigator

Signature of Investigator

Investigation Date & Time

District/State official Siganature

Past History Details (Non Mandatory)

Duration prior to
Name of Disease getting admitted Only
Yes/NO
High Blood pressure Yes No
Diabetes Yes No
Asthma Yes No
Cancer Yes No
IHD/MI Yes No
Tobacco Yes No
Alcohol Yes No
Others

Fraud Investigation and Medical Audit Manual  |  21

 Annne exurre 4::
On-Sitte In
nvesstigaatio
on
Foorm
m
AY
YUSHMAAN BHAARAT –
PRADHAN MANTRI
M JAN AR
ROGYA YYOJANA
A
 Annexu
ure 4 – On Site
S Hospital Investig
gation

Source: Jo
oint Learning Network Toollkit to develop
p and strength
hen medical au
udit systems

1. On-s
site investig
gation at hos
spital

A.. Informatio
on of the In vestigation
n Team

Name of the spot

s on-site investigation
n team leade
er
Number of pe
eople in the on-site
o inves
stigation team
Names of people in the on-site
o inves
stigation tea
am 1.
m
members 2.
3.
4.
5.
D
Date of visit to
o hospital

Time of field visit

v

B. Information of tthe Hospita

al

Name of the hospital

h

Lo
ocation (State, District, Block
B and Village / Ward
d)

Hospital ID

Number of be
eds

Tyype of hospiital (public / private)

Signature
es of Audit te
eam leader and membe
ers:
1)
2)
3)
4)
5)

Fraud Investigation and Medical Audit Manual  |  23

 2. Onsite or field in
nvestigation Triggers

RIGGERS FOR
TR F ONSITE E SOURCE OF F TOOLS F FOR PROCES SS OF ON-S SITE
IN
NVESTIGAT TION DATA
D INVESTIIGATION INVESTIGATION
Claims pattern triggers: E.g.;
E Claims
C details
s *Checklisst for -facilityy Based on n the predete ermined
1. High inncidence of day- su
ubmitted by inspectioon at triggers hhospitals witth
care procedures
p In
nsurance hospital, evaluation possible deviations from
(<24ho ours) Companies
C / of inpatie
ent case scheme g guidelines a are
2. Repea ated blockingg of State Health records & availabilityy identified
d and listed.
higherr-priced pack kages Agency
A / of staff On site vvisit to hospittals by
(>Rs. 15,000) NHA server *Questio onnaire for medical a audit team m members
3. Length h of stay at hospital
h deetails intervieww of and invesstigation of
> 15 days
d beneficiaary availabilitty of facility,
4. Number of claims infrastruccture & staff will be
disprooportionate with
w bed done.
strenggth of hospitaal Case reccords of patie ents will
district claims more
5. Inter-d be looked d for treatme ent given.
compa ared to with--in Intervieww of beneficia aries
district claims regarding g quality of ccare and
6. Blocking of cases, that a any dema and of mone ey for
hospittal is not equuipped treatmen nt or investigation.
for Detailed report of the e
7. Showiing admissio on in investigaation will be ssubmitted
ICU thhough not eq quipped for empa anelment and d
8. Blocking of multiple disciplina
ary committe ee for
packages/procedu ures further acction.

Unethical med dical practice Claims

triiggers:
1. ICU ad dmission forr more
than 7 days
2. Diseas ses/conditions not
relatedd to age/gennder of
patiennt
3. Possib ble Conversion of
Outpa atient cases to
t co
Inpatieent cases
4. Hysterrectomy perfformed
for pattients <40yrss age
5. Catara act related
surgerries for <45 yrs.
y guidelinees. Facility,
Age
6. Claims s pattern of hospital
ent from that of
differe
district
C details
s *Checklisst for -facilityy Based on n the predete ermined
su
ubmitted by inspectioon at triggers aand
In
nsurance hospital, evaluation complain nts/grievance es
Companies
C / of inpatie
ent case hospitalss with possib ble
State Health records, evaluation deviationns from sche eme
Agency
A / of operattion theatre, guidelinees are identiffied and
NHA server evaluatioon of ICU & listed.
deetails & availabili ty of staff On site vvisit to hospittals by
omplaints orr *Questioonnaire for medical a audit team m members
grrievances interview
w of – case re ecords of patients are
aggainst the beneficiaary looked foor procedure es &
hoospital. *Clinical surgeriess performed using
protocol//pathways clinical protocol/pathways
infrastruccture and reccords of
hospital iinspection w will be
done.
Detailed report of the e
investigaation will be ssubmitted
for empa anelment and d
disciplinaary committe ee for
further acction.

24  |  Fraud Investigation and Medical Audit Manual

Frraudulent ac
ctivities triggers Claims
C details
s Evaluatio
on of Based on n the predete ermined
1. Odd hour
h transacttions su
ubmitted by completee process off triggers aand
2. Unusu ual increase in In
nsurance the sche me based complain nts/grievance es
transaactions Companies
C / on guide
elines. hospitalss with possib ble
3. Claims s pattern of hospital State Health deviationns from sche eme
differe
ent from that of Agency
A / guidelinees are identiffied and
district NHA server listed.
deetails & On site vvisit to hospittals by
co
omplaints orr medical a audit team m members.
grrievances Complete e process off the
aggainst the scheme ffrom registra ation to
hoospital. discharge e (including records
of buildin
ng, accountss etc.) is
reviewed d and evalua ated using
checklists, clinical prrotocol &
scheme g guidelines too detect
any fraud dulent activitties.
Post disccharged beneficiaries
will be intterviewed foor
detectingg quality of sservice &
any fraud dulent activitties.
Detailed report of the e
investigaation will be ssubmitted
for empa anelment and d
disciplinaary committe ee at
SHA for ffurther legal action.

Fraud Investigation and Medical Audit Manual  |  25

 3. Chec site/Field Investigation
cklist Template for Ons ns

PM-JAY REGISTRATIION/ HELP D

DESK CHEC
CKLIST
STION
QUES Response
e REM
MARKS
Is therre any signbooard outside
e hospital sh
howing that itt is
empan nelled in sch
heme? Yes / No
Is therre any signag
ge inside the
e hospital off giving inforrmation
about the scheme? Yes / No

Is therre a scheme help desk at

a the hospita
al? Yes / No

Is therre a staff/ Aro

ogya Mitra managing
m the help desk?
? Yes / No
Is therre any schem
me patient admitted in th
he hospital a
at the time
of the visit? Yes / No

If yes, how many scheme

s patients are adm
mitted Yes / No

Is any Package blo

ocked without patient be
eing admitte
ed? Yes / No

If yes, how many packages

p arre blocked? Yes / No

CHEC
CKLIST FOR
R AVAILABILITY OF ST
TAFF AT TH
HE HOSPITA
AL
STION
QUES Response
e REM
MARKS

At leas
st 1 medical officer (RMP
P) available at all times
Yes / No

At leas
st 1 nurse (R
RNP) availab
ble at all time
es
Yes / No

At leas
st 1 informattion providerr is present (staff)
( at all ttimes.
Yes / No
There is a registerred nurse ap
ppropriately qualified
q and
d/or
experienced who is i responsible for the maanagement o of each
ward on
o 24x7 basis Yes / No

There is a system for calling specialists

s in an emergen
ncy
Yes / No
Emerg gency departtment is man
nned by an MBBS docto
or on 24x7
basis

All trea
ating doctors
s details ava
ailable at the
e hospital
Yes / No

26  |  Fraud Investigation and Medical Audit Manual

 CHEC
CKLIST FOR
R EVALUAT
TION OF SU
URGICAL PR
ROCEDURE
ES
QUESSTION Response
e REM
MARKS
Docum
mented pre-a anaesthesia assessmen
nt by a qualiffied
anaesthesiologist Yes / No
Inform
med consent for administtration of Ana aesthesia iss obtained
by the Anaesthetis st Yes / No
Details
s of Recorde ed monitoring of heart ra
ate, cardiac rrhythm,
atory rate, BP, O2 satura
respira ation, airway
y security, annd potency
and level of anaes sthesia Yes / No
OT NO OTES- Detaiils of procedure done by y respective surgeon of
concerned speciallity Yes / No

Patien
nt’s post anaesthesia sta
atus is monitored and do
ocumented.
Yes / No

CH
HECKLIST FOR
F OPERA
ATION THE
EATRE/DEPA
ARTMENT
STION
QUES Response
e REM
MARKS

OT Ste
erilization facilities functional.
Yes / No
Adequ uate lights (g
general level illumination
n) and Air co
onditioning
is prov
vided in each h OT Yes / No
A heig
ght adjustable OT Table, shadow les ss Operatingg light is
availab
ble. Yes / No
The opperation theaatre is equip
pped for its purpose
p and includes:
- Anaeesthetic macchine and ventilator
- Laryn
ngoscopes (Adult
( / Paed
diatric)
- Endootracheal tubbes/laryngeaal masks
– Airw
ways
- Nasaal tubes
- Suctiion apparatuus and conne ectors
– Oxyggen
- Drugs for emerge ency situatio
ons
- Monitoring equippment including ECG, ET TCO2 (wherre
applicaable), pulse oximeter annd blood pres ssure, cardia
ac monitor,
Defibrillator Yes / No

Runnin
ng tap waterr supply in OT
O
Yes / No

Hot wa
ater supply in OT
Yes / No
Proced dures are avvailable and up to date fo
or:
med patient consent
- Inform
- Pre-ooperative assessment
- Post--operative ca
are Yes / No

Fraud Investigation and Medical Audit Manual  |  27

 Emerggency powerr supply connection is av
vailable for a
all OT
ment’s (embedded UPS))
equipm Yes / No
abels are us
Steri la sed for mainttaining the quality
q of auttoclaving
(mand datory for ophthalmic spe
ecialty) Yes / No
Functional annual maintenanc
ce contract fo
or all major
ment’s.
equipm Yes / No
The OT complex iss divided intto sterile, cle
ean, protectivve and
sal zones (m
dispos maintained ph hysically) Yes / No

Regula
ar documentted autoclav
ving of instru
uments & line
en.
Yes / No
Carbonization of th
he OT, Labo
our Room affter every pro
ocedure
mented)
(docum Yes / No
ar validation tests for ste
Regula erilization (ca
arried out an
nd
docum
mented) Yes / No

CHECKLIST FOR EVALUATIION OF INT ENSIVE CA

ARE UNIT (IC
CU)
QUESSTION Response
e REM
MARKS
ICU-deesignated air conditioned space with h Standard IICU bed,
ment for the constant mo
equipm onitoring for vitals, emerrgency
crash cart, defibrillator, ventila
ators, suction
n pumps, be edside
oxygenn facility Yes / No
Anaessthesiologist--Intensivist Nursing
N Stafff: B Sc
Nursin
ng/Diploma have
h 2 yearss of ICU experience

What isi the Nurse Patient Rattio? Yes / No

Standb by Generato or/inverter ins
stalled in ICU to meet e mergency
power supply. Yes / No
Policie
es and proce edures for ad dmission, disscharge crite
eria for its
intensive and high h dependenc cy unit, documented con ntrol of
infectio
on rate in IC
CU, re-admis ssion rate, re
e-intubation rrates. Yes / No

ESTIONNAIRRE FOR PATIENTS

QUE P (B
BENEFICIA
ARY) ADMIT
TTED IN THE
E HOSPITAL
STION
QUES Response
e REM
MARKS
Age ________ Y
Years
Gende
er
Relatio
on with Head
d of Househ
hold
Does patient
p have
e E-Card with
h him/ her? Yes / No
E Card
d number
Date of
o Admission
n in the hosp
pital

28  |  Fraud Investigation and Medical Audit Manual

 Since how many days
d patient is admitted?
?
Was fingerprint ve
erification done through a fingerprint scanner? Yes / No
Do youu know abouut any provission of transport cost allo
owance in
the scheme? Yes / No
Was thhe patient prrovided with food during stay at the hospital? Yes / No
Were all
a patient reelated querie
es answered d during yourr visit to
hospita
al for treatment under th
he scheme? Yes / No
Excellent-1
Very good-22
How would
w you rate your satis
sfaction abou
ut the treatm
ment
Good-3
provided at the ho
ospital?
Average-4
Poor-5

Were you/your
y fam
mily forced to
o give mone ey for treatmeent? Yes / No
If yes, total amounnt medical exxpenditure paid
p by patie
ent/family
for trea
atment
Will yoou recommend your rela atives/friends
s to take trea
atment from
the same hospital? ? Yes / No
Treated bad dly-1
Poor qualityy care-2
If no, why?
w
Not receptivve to
RSBY patieents-3

What are
a the patie
ent’s sugges
stions for imp
proving the sscheme?

Undertaking by Hos
spital

o certify thatt the informa

This is to ation provide
ed by me/uss about hosp
pital, District/ State, is ttrue to the
best of my/our kn
nowledge and is base umentation and proce
ed on docu ess followed
d in this
hospital/iinstitution. I// We had not suppressed any inform
mation or facct. Further, I// We undersstand that,
in case the
t informattion provided is found to
t be incorrrect and bassed on supp
pression of facts, the
hospital stands
s to forrfeit its claim
ms.

Name/Signature/Date with Seal of the Autho

orized Perso
on.

Fraud Investigation and Medical Audit Manual  |  29

 Annne exurre 5::
Mo
ortallity Aud
A dit FForm
m
AY
YUSHMAAN BHAARAT –
PRADHAN MANTRI
M JAN AR
ROGYA YYOJANA
A
Annexu
ure 5 – Morrtality Audiit

Source: www.sast.gov.i
w in

Section 4.1. and 4.2. is to

t be filled by the hospitals
s and sent at th
he time of ben
neficiaries’ de
eath (within 48
8 hrs)

1. Death Summary y (A brief noote)

x Hospital
H Namme
x Hospital
H ID
x Patient
P e-card number)
ID (e
x Patient
P Charracteristics
x Name
N
x Age
A
x Sex
S
x Length
L of Ad
dmission in days
d
x Clinical
C Diaggnosis (es) on
o Admission
n
x Clinical
C diagnosis(es) on n Death
x Emergency
E or Elective
x Date
D of Admmission:
x Date
D of Deatth:

2. Progress of the patient durring hospita

alization
x Abnormal
A Investigations s:
x Hematology
H , Biochemisttry, Radiolog gy, Microbio logy Others
x What
W was th he treatment provided?
x Were
W there any
a clinical errors,
e omiss sions, proceess problemss that hinderred the proce ess of
giving
g good quality care? ?
x Were
W there identifiable
i clinical
c risks//incidents?
x Were
W a of the clinical risks/incidents due
there any e to delay in
n Diagnosis, Delay in Treeatment,
Medical
M Clin
nical Errors, Nursing
N Clin
nical Errors, Medication Errors, Proccess Errors
x Please
P give further details below
x Were
W all stan
ndard protoc cols followedd?
x What
W accord ding to the trreating doctoor is the cau se of death and contribuuting factorss?
x Any
A other re emarks

Fraud Investigation and Medical Audit Manual  |  31

 Mortality
y Audit Com
mmittee

The commmittee com mprises of individuals constituted from the h hospital tha
at representt the key
departme
ents - including management, treatin
ng doctors a
and support d
departmentss.

Aims and guideline

es for condu
ucting morttality audits
s

The aim is to ascerta ortion of pattients who d ied because

ain the propo e of 'problem
ms in care', d
defined as
patient harm
h resultin
ng from hea althcare pro
ocesses incl uding acts of omission n (inactions), such as
failure to
o diagnose and treat, or o from acts s of commisssion (affirm
mative actionns) such ass incorrect
treatmen nt or manage ement. The focus shoulld be on the e systems and processe es of care aand not on
individuaal performanc ce.

Areas to
o be identified for each
h case

Area of CONCERN
C is where the clinician believes that a
areas of care
e SHOULD h
have been b
better.

An ADVERSE EVENT is an unintended

u injury cause ed by mediccal manage ement rather than by
disease process, wh
hich is sufficiently seriou
us to lead to prolonged hospitalization or to temmporary or
permaneent impairme atient at the time of disccharge, or w
ent or disability of the pa which contrib
butes to or
causes death
d

mmittee wou
The com uld prepare ‘DEATH AU
UDIT REPO RT’ as men
ntioned belo
ow :

Section A: General Information

n

x Patient
P details:͒
x Name:͒
N
x Age:
A
x Sex:͒
S
x DOA:
D
x Date
D of Surg
gery:͒
x Diagnosis:
D
x Treatment
T given:
x Surgery/Pro
S cedure/ Rad
diotherapy/ Chemothera
C py/ Others ((specify)
x Hospital
H nam
me:
x Name
N of Tre
eating Doctor

32  |  Fraud Investigation and Medical Audit Manual

Section B - Case Summary

Please provide
p mmary of the Case in th
a sum he form of n narrative – in
ncluding com
mplaints at th
he time of
admissio
on, chronolog
gy of events up to death
h of the patie
ent –

Section C: Case As
ssessment

ONCERN or ADVERSE EVENTS in

1. Werre there any areas of CO n the manage ement of this patient?
- Yes/No
2. Wass surgery performed? Yees/ No
3. Werre there any areas of Co
oncern, or Ad
dverse Even
nts in any of the following
g?

Operation/procedure
e was perform
med, or treatment provid
ded? Yes N
No NA

Pre-anes
sthetic check
kup/fitness fo
or surgery/trreatment

Decision
n to operate

Choice of
o operation

Timing of operation (too

( late, too
o soon, wron
ng time of da
ay)

Intra-ope
erative proce
ess

Problems
s in functioning of OT

Grade / experience
e of
o surgeon deciding
d

Grade / experience
e of
o surgeon operating
o

Post-ope
erative period
d

4. Was s this patientt treated in a critical care

e unit (ICU oor HDU) duriing this admission?
Yes//No
5. If no
o, should this
s patient hav ve been prov vided criticall care in ICU
U/HDU?
Yes// No

Fraud Investigation and Medical Audit Manual  |  33

 Opinion of the Audit committe
ee regarding
g overall ris
sk of death

- Minimal/ Mild/
M Modera
ate/ Severe

If there any
a areas of CONCERN or ADVERS
SE EVENTS
S in the mana
agement of tthis patient:

Describe
e the significa
ant event/s during
d the co
ourse of trea
atment in the
e hospital:

Note any
y areas of co
oncern or Ad
dverse Eventt

Note if th
hese areas caused
c o the following:͒
any of

Made no difference to
t outcome __________
_ ___________
___________
__________
___________
______

May have
e contributed
d to death__
__________
___________
__________
__________
_________

Caused death
d of patient who would otherwis
se be expectted to survivve_________
_________

Was the death preve

entable?͒(i) Definitely͒(ii
D i)Probably͒((iii) Probablyy not͒(iv) Definitely not͒((v) Don’t
know

Section D: Record of
o cause of death

Hospitall mortality audit

a comm
mittee review
w findings:

Primary cause
c of dea
ath: _______
__________
__________
___________
__________
_________

ICD code
e: ________
___________
__________
__________
___________
__________
________

Seconda
ary cause of death: ____
___________
__________
__________
___________
_______

ICD Code: ________

__________
___________
__________
__________
___________
_____

Antecede
ent cause off death: ____
__________
__________
___________
__________
_________

ICD code
e: ________
___________
__________
__________
___________
__________
________

FINAL RECOMMEN
R NDATIONS (if any) OF THE
T MORTA
ALITY AUDIIT COMMITT
TEE

1. _____
___________
__________
___________
___________
__________
__________
________
2.______
__________
___________
__________
__________
___________
__________
________
3.______
__________
___________
__________
__________
___________
__________
________

34  |  Fraud Investigation and Medical Audit Manual

Attestatiion by the Mortality
M Au
udit Committtee membe
ers:

Name
N Designatio
on Signatture

Date:

Fraud Investigation and Medical Audit Manual  |  35

 First Line Assessment Form on Hospital
Mortality Audit Report

Case Note Review

A case note review is a peer assessment of the death of a patient. It should be
carried out in a spirit of sympathetic enquiry and provide sufficient detail for a
clear view of events. Points should be made in a detached manner and any
opinions expressed should be objective and reasonable.

Aim
The aim is to ascertain the proportion of patients who died because of 'problems
in care', defined as patient harm resulting from healthcare processes including
acts of omission (inactions), such as failure to diagnose and treat, or from acts of
commission (affirmative actions) such as incorrect treatment or management.

Criteria for Ranking

An area of CONSIDERATION is where the clinician believes areas of care
COULD have been IMPROVED or DIFFERENT, but recognises that it may be an
area of debate.

An area of CONCERN is where the clinician believes that areas of care SHOULD
have been better.

An ADVERSE EVENT is an unintended injury caused by medical management

rather than by disease process, which is sufficiently serious to lead to prolonged
hospitalisation or to temporary or permanent impairment or disability of the
patient at the time of discharge, or which contributes to or causes death

36  |  Fraud Investigation and Medical Audit Manual

Section A: General Information

Patient details:

Name:

Age: Sex: Pre-auth No.

DOA: DOD:

Diagnosis:

Reviewing Doctor:

Please provide a summary of the Case in the form of narrative

___________________________________________________________

Section B: Case Note Assessment

Were there any areas of CONSIDERATION, of CONCERN or ADVERSE EVENTS in the

management of this patient?

Yes

No

1 Describe the most significant event:

Was surgery performed? Yes No

Were there any Areas of Consideration, of Concern, or Adverse Events in any of the
following areas if an operation was performed?

Discussion points Yes No N/A

Pre anaesthetic check up/fitness for surgery
Decision to operate
Choice of operation
Timing of operation (too late, too soon, wrong time of day)
Intra-operative process
Problems in functioning of OT
Grade / experience of surgeon deciding
Grade / experience of surgeon operating
Post operative period

Fraud Investigation and Medical Audit Manual  |  37

 If yes above, provide details of

Area of:

Consideration

Concern

Adverse Event

Which:

Made no difference to outcome

May have contributed to death

Caused death of patient who would otherwise be expected to survive

Was it preventable?

Definitely

Probably

Probably not

Definitely not

Don’t know

Please provide evidence to support your statements given above by referring to specific
points relating to any investigation reports or progress of the patient, treatment provided
etc., which substantiate your observations

______________________________________________________________________________

2 Describe the second most significant event:

______________________________________________________________________________

Area of:

Consideration Concern

Adverse Event

Which:

38  |  Fraud Investigation and Medical Audit Manual

Made no difference to outcome

May have contributed to death

Caused death of patient who would otherwise be expected to survive

Was it preventable?

Definitely

Probably

Probably not

Definitely not

Don’t know

Please provide evidence to support your statements given above by referring to specific
points relating to any investigation reports or progress of the patient, treatment provided
etc., which substantiate your observations

_____________________________________________________________________________

_____________________________________________________________________________

3 Describe the third most significant event:

Area of:

Consideration Concern

Adverse Event

Which:

Made no difference to outcome

May have contributed to death

Caused death of patient who would otherwise be expected to survive

Was it preventable?

Definitely

Probably

Fraud Investigation and Medical Audit Manual  |  39

 Probaably not

Definiitely not

Don’t know

Pleasse provide evvidence to su

upport your statements
s given above bby referring tto specific
points relating to any investigation reportss or progresss of the patieent, treatmennt provided
etc., which
w substaantiate your observations
o s

______________________________________________________________________________________

Hospital mortalityy report revieew findings:

Recorrd the cause of

o death ( as given)
g
______________________________________________________________________________________
______________________________________________________________________________________

Concllusion:

Primaary cause of death: ________________________________________________________________

ICD code:
c __________________________________________________________________________

Seconndary cause of
o death:_____
_________________________________________________________

ICD code:_______
c ______________________________________________________________________

Anteccedent cause of death: ______________________________________________________________

ICD code:
c _____________________________________________________________________________

Was there
t enough
h information
n to come to a conclusionn?

Yes No

If NO,, what informaation was lackking?

______________________________________________________________________________________

Paym
ment:

40  |  Fraud Investigation and Medical Audit Manual

Pre-auth approved amount:

Amount Claimed:

Amount Recommended:

Name of the first line assessor:

Designation

Date:

Signature

Fraud Investigation and Medical Audit Manual  |  41

 Annne
exurre 6::
Claim
C m Auditt Fo orm
AY
YUSHMAAN BHAARAT –
PRADHAN MANTRI
M JAN AR
ROGYA YYOJANA
A
 m Specific Information
A. Claim
1. Name
N of Patient:
2. PM-JAY
P card
d no.:
3. Name
N of Hosspital:
4. Package
P Boooked:
5. Package
P Amo ount:
6. Status
S of Claim:

ument Valid
B. Docu dation

Yes No

Doo the photos taken at thee time of admmission and discharge m

match with
1
thee photo on thhe card?
2 Dooes the inforrmation mentioned on the card matcches with thee
infformation meentioned on the claim do ocuments?
3 Arre the sympto oms consisttent with the diagnosis?

4 Arre investigation report ou

utcomes con
nsistent with the diagnossis?

5 Do
oes the diagnosis match
h the package blocked?

6 Dooes the inforrmation mentioned on the discharge

e card consisstent with
the
e package blocked?
b
7 Waas the paymment for entirre approved amount madde?

8 Fo
or rejected ca
ases, was th
he reason off rejection jusstified?

C. Any other
o remarrks

D. Finall Conclusion

Date:
nd Signaturre of the inv
Name an vestigator:

Fraud Investigation and Medical Audit Manual  |  43

 Annexure 7:
Reporting Format
Ayushman Bharat –
Pradhan Mantri Jan Arogya Yojana
 Annexure 7: Reporting Format
Name of the state Gujarat
Period of performance
Date of submission
Total No of cases triggered for investigation/audit
A B C D E F G H
State Code (TMS) Total Preauths Total No of cases trigerred for further review Total amount Total No. % cases
raised (value) of of cases investigated/ audited
cases that were investigated / out of triggered (G/
triggerred audited (C+D+E))
System Cases referred Cases referred by
generated by Processing Claims Review/
cases Team Mortality Committee

Fraud Investigation and Medical Audit Manual  |  45

 Outcomes Field Investigation
I J K L M N O
Total amount of % cases confirmed Total Cases sent for Field Number of cases where fraud was Total amount of
cases where fraud as fraud of total Investigation confirmed after field investigation cases where fraud
was confirmed investigated (I/G) was confirmed post
field investigation
Hospital Beneficiary Hospital Beneficiary

46  |  Fraud Investigation and Medical Audit Manual

 Medical Audit Mortality Audit
P Q R S T U
Total Cases sent for Number of cases Total amount of Total Number of Percentage of Number of cases
Medical Audit where fraud was cases where fraud mortalities mortality audits done where death was due
confirmed after was confirmed post to hospital negligence
medical audit medical audit

Fraud Investigation and Medical Audit Manual  |  47

 Action post Confirmation of fraud
V W X Y Z AA AB AC AD
Total Number Number of No of No of No. of No of Amount No of Amount of
of hospitals hospitals hospitals hospitals hospitals hospitals of penalty hospitals punitive
involved in against which where reported deempanelled penalised recovered against which Recoveries
fraud action was showcause to SEC for FIR is lodged Made
initiated was issued suspension

48  |  Fraud Investigation and Medical Audit Manual

 Beneficiary Audit (ecard /golden record)
AE AF AG AH
Number of golden records created Number of cases selected Number of cases found Action Taken (List the steps taken
in CSC for audit fraudulent after fraud is confirmed)

Fraud Investigation and Medical Audit Manual  |  49

 An
nneexurre 8::
Hand
H dling Difficcult
Situa
S atioons
AY
YUSHMAAN BHAARAT –
PRADHAN MANTRI
M JAN AR
ROGYA YYOJANA
A
Handdling Difficul
D lt Situa
ations during
g Field
d
Inves
stigation andd Audit
A. Non--cooperation from ben neficiary sidde: if there is low coo operation froom beneficia
ary during
verific
cation or beneficiary
b is
i not availlable to ve erification, th he team w will be sendding three
Querries/Remindeer to benefic
ciary to coop
perate in verrification. if th
here is no re
esponse, the
e case will
be cloosed under non-cooperaation/ non-su
ubmission off required do ocuments.

B. Non--cooperation from Hos spital/provider: if theree is non-coo operation fro

om Hospital/provider,
team will be sendding three Queries/Rem
Q inder to hosspital, if there
e is no respo
onse, the cla
aim will be
rejectted and the amount willl be recoveered under n non-coopera ation/ non-su
ubmission oof required
document

C. Alleggation of Bribe/
B Misb
behave on investigato or: If theree is any pa articular alle
egation of
bride/misbehave on particula ar investigato or, will set u
up a third party to investigation agenncy to rule
he actual fac
out th ct in the cas
se, if allegatiion found to be correct, action to be e taken and dismissal
of the
e agency forr future case
es

D. Casees missed out

o for inve estigation/VVerification: If any case
e missed ou
ut while assigning the
case to investig vestigation, that need to take it o
gator for inv on highest priority to assign to
stigator
inves

E. Not able
a to assiign the casee to SHA in nvestigator//NHA team due IT/ technical issue e: in such
situattion if system
m is not worrking or therre is any IT issue, wherre our NHA team or FCM team is
not able
a to assign the triggered case to investigation n/FCM teamm, will do thiss exercise o
on manual
basis
s to investiga ate the case without anyy fail.

F. Veriffication of cases
c on Hoolidays: On any holidayy or especially on Saturd
day and Sunday, FCM
team will coo ordinate with internall team/inve estigator teelephonicallly and sh hare the
inves
stigator/intern
nal inputs on
n telephone//mobile.

Fraud Investigation and Medical Audit Manual  |  51

 Annne
exurre 9::
Trig
gge
er Poointts
AY
YUSHMAAN BHAARAT –
PRADHAN MANTRI
M JAN AR
ROGYA YYOJANA
A
Triggers Poin
nts

1.. Claim His

story Trigge
ers

x Impers sonation.
x Misma atch of in-hoouse docume ent with subm mitted docum ments.
x Claims s without sig
gnature of thhe beneficiarry on pre-autthorisation foorm.
x Secon nd claim in thhe same yea ar for an acuute medical i llness/surgiccal.
x Claims s from multip s with same owner.
ple hospitals
x Claims s from a hospital locate ed far away from benefiiciary’s resid dence, pharrmacy bills a away from
hospittal/residencee.
x Claims s for hospita
alization at a hospital alre
eady identifiied on a "waatch" list or b
black listed h
hospital.
x Claims s from members with no o claim free years,
y i.e. re
egular claim history.
x Same beneficiary claimed in multiple
m placces at the sa ame time.
x Excesssive utilization by a specific membe er belonging to the benefficiary Familly Unit.
x Delibeerate blockinng of higher-priced packa age rates to claim highe er amounts.
x Claims s with incom
mplete/ poor medical histtory: compla aints/ presen
nting symptoms not mentioned,
x only line of treatment given, supporting do ocumentatio on vague or iinsufficient.
x Claims s with missing information like postt-operative h histopathologgy reports, ssurgical / annaesthetist
notes missing in surgical
s case
es.
x Multip
ple claims witth repeated hospitalizatiion (under a specific pollicy at differe ent hospitalss or at one
hospittal of one me ember of the e beneficiaryy family unitt and different hospitals for other me embers of
the be
eneficiary fam mily unit,
x Multip
ple claims tow wards the en nd of policy cover
c period d, close proxximity of claims.

2.. Admissio
ons Specific
c Triggers

x Memb bers of the sa

ame beneficciary family getting
g admittted and discharged tog
gether.
x High number
n of ad
dmissions.
x Repeaated admissions.
x Repeaated admissions of mem mbers of the same benefficiary familyy unit.
x High number
n of ad
dmission in odd
o hours.
x High number
n of ad
dmission in weekends/
w holidays.
h
x Admisssion beyond d capacity off hospital.
x Average admissio on is beyond bed capacitty of the proovider in a month.
x Excesssive ICU (In
ntensive Care Unit) admission.
x High number
n of ad
dmission at the
t end of th he Policy Co
over Period.

Fraud Investigation and Medical Audit Manual  |  53

 x Claimss for medic cal manageement admisssion for eexactly 24 h hours to co
over OPD ttreatment,
expennsive investig
gations.
x Claimss with Lenggth of Stay (LOS) which is in sign ificant varia
ance with th
he average LoS for a
particu
ular ailment.

3.. Diagnosis
s Specific Triggers
T

x Diagnosis and trea atment contradict each other.

o
x Diagnostic and tre eatment in different geoggraphic locattions.
x Claims s for acute medical
m Illne e uncommo n e.g. encep
ess which are phalitis, cere
ebral malariaa, monkey
bite, snake
s bite ettc.
x Ailmen nt and gende er mismatchh.
x Ailmen nt and age mismatch.
m
x Multipple procedurres for sam me beneficia
ary – blockiing of multiple packag ges even th hough not
requireed.
x One-tiime procedu ure reported many times s.
x Treatmment of dise eases, illnessses or accid
dents for whhich an Emp panelled He ealth Care P Provider is
not eqquipped or empanelled fo or.
x Substitution of packages,
p fo
or example, Hernia ass Appendiccitis, Conservative trea atment as
Surgiccal.
x Part ofo the expe enses collec cted from beneficiary ffor medicine es and scre eening in a addition to
amoun nts received by the Insurer.
x ICU/ Medical
M Trea atment bloccking done for
f more tha an 5 days o of stay, othe er than in the case of
critical illnesses.
x Overa all medical management
m exceeds moore than 5 d ays, other th
han in the caase of critica
al illness.
x High number of cases treatted on an out-of-pocke
o et payment basis at a given provvider, post
consumption of fin nancial limit.

4.. Billing an
nd Tariff bas
sed Triggerrs

x Claimss without supporting pree/ post hospitalisation paapers/ bills.

x Multip
ple specialty consultation
ns in a single
e bill.
x Claimss where the cost of treattment is muc ch higher thaan expected d for underlyying etiology..
x High value
v claim from a sm mall hospitall/nursing hoome, particu ularly in classs B or C cities not
consis
stent with ailment and/orr provider prrofile.
x Irregular or ino ordinately delayed
d synchronizatio on of tran nsactions to o avoid cconcurrent
investigations.
x Claimss submitted that cause suspicion
s du
ue to format or content th hat looks "to
oo perfect" in
n order.

54  |  Fraud Investigation and Medical Audit Manual

 x Pharm
macy bills in chronolo ogical/runnin ng serial n number or claim doccuments with colour
photoccopies. Perfeect claim file
e with all criteria fulfilled with no deficiencies.
x Claimss with visible
e tempering of documen nts, overwritiing in diagno osis/ treatme
ent papers, discharge
summmary, bills etc.
e Same handwriting
h and flow iin all docum ments from m first presccription to
admisssion to disccharge. X-ray y plates with hout date an nd side prin
nted. Bills geenerated on a "Word"
documment or docu uments witho out proper siignature, na me and stam mp.

5.. General

x Qualiffication of pra
actitioner do
oesn't match h treatment.
x Specia alty not available in hosp
pital.
x Delaye ed informatioon of claim details
d to the
e Insurer.
x Conveersion of out-patient to inn-patient casses (comparre with historrical data).
x Non-ppayment of trransportation n allowance.
x Not dispensing po ost-hospitaliz
zation medic cation to benneficiaries.

Fraud Investigation and Medical Audit Manual  |  55

NOTES
NOTES
NOTES