eMedinewS Editorial

Health Care 716 Comments

Stop commission and increase the fee

Are TPAs making us corrupt?

The current policies of TPAs, Insurance Laws, empanelment with various public sector undertakings, CGHS, ECHS etc. are making the doctors shift to unethical practices. Here are few examples:

  1. A female patient was admitted with acute disk prolapse with restricted SLR (Straight leg raising) and root pains. She was admitted for observation and possible epidural injection or surgery on SOS basis. She responded to conservative treatment. Her cashless Mediclaim was denied on the grounds that no acute intervention was done. The TPA doctor personally told me that the claim was not passed as no epidural was given nor was any surgery done. He even said that in such cases, one should go for epidural if a cashless is needed. 99% doctors in this situation will get carried away and give an epidural, which otherwise could have been avoided.
  2. A patient was admitted with persistent diarrhea, low blood pressure and dehydration. Following international guidelines, she was treated with oral drugs. She responded to ORS but the cashless mediclaim was denied on the grounds that no IV fluids were given. This clause of Mediclaim is forcing the doctors to start IV drips whether or not necessary.
  3. A patient was admitted with 104 degree persistent fever due to enteric fever. She was treated with continuous tepid cold sponging and a combination of oral antibiotics and anti pyretics. Cashless Mediclaim was denied as no IM antipyretics, IV fluids or IV antibiotics were given. This clause is sending out a wrong message to doctors that no fever should be treated in a hospital without IV antibiotics or without IV fluids.
  4. A patient was admitted in the hospital transferred from an Arabian country for a cardiac intervention. An advance of Rs. 3 lakh was charged. Angiography was done which showed less than 70% blockage. Interventional cardiologist refused to intervene but the agent who brought the patient insisted that the patient has come from Arabian country and intervention had to be done. If one doctor will not do the other will do. A bypass surgery was done, which was not necessary.
  5. Only 1% room rent is allowed in any cashless insurance. But no such clause exists for the doctors’ fee. The hospitals which have full time paid consultants charge exorbitant fee taking advantage of this clause.
  6. The insurance clauses are also luring the surgeons to split one surgery into two and charge more money. We have known cases where a hysterectomy was charged as hysterectomy+ oophorectomy + appendectomy + vaginal wall repair.
  7. A loophole in Mediclaim where separate charges are reimbursable for surgeon, anesthesia, anesthetist and operation theatre has resulting in most corporate houses charging more. Initially there were only two charges – surgeon and operation theatre. Operation theatre charges included charges for anesthesia and for anesthetist. Now all four charges are billed separately.
  8. 10-30% overhead charges are billed over and above the total bill which is nothing but commissions paid to the referral doctors or to the agents who are soliciting patients to the corporate hospitals.
  9. A patient’s bypass surgery was done a day before retirement as post retirement, he would be losing his reimbursement benefits. Otherwise there was no absolute indication for bypass surgery.
  10. Most of the known patients get their insurance done after they fall sick and claim reimbursement. For this the only way claim can be managed is with the help of the treating doctors who will have to make false declaration about the sickness.
  11. In many hospitals, CGHS admissions are only allowed for one or two specialties. For example, if a hospital is empanelled only for cardiology, many of the non-cardiac patients will be admitted in intensive coronary care unit showing them as cardiac illness. To justify cardiac admission, unnecessary cardiac tests will be performed and billed.
  12. CGHS pays less than Rs 100 per consultation to OPD and IPD doctors. The loss of revenue to the doctors invariably will be compensated by billing unnecessary investigations or surgeries which are paid reasonably by CGHS. For example, cardiologist will try to cover his consultation through unnecessary angioplasty or putting a stent.

Most of the doctors are honest but the system is so corrupt that most doctors, especially the younger lot, will get lured into this system.

Dr KK Aggarwal
Editor in Chief