Insurance companies have come up with irrational cost cutting of medical insurance amounts in order to reduce incurred business losses. The companies are offering a list of fixed costs in MOU for Preferred Provider Network (PPN) thus giving an excuse of streamlining the service for common policy holders, said Ahmedabad Medical Association (AMA) officials who briefed the media on the logjam between public sector insurance companies and medical fraternity- the issue on which DNA first broke a story in April. The new mediclaim insurance norms reportedly come into effect from May 16.

Irrational cuts and non-transparent grading of PPN hospitals are the two vital issues which are not acceptable, says the medical fraternity. “After detailed study, AMA members have found that the entire process of new clashes and mediclaim arrangements are not transparent,” said Dr Jashwantsinh Darbar, president, AMA.

AMA has publicly appealed to the state’s doctors and hospitals to not sign the recent PPN-TPA MOU due to its lack of transparency and dictatorial norms, which violate rights of patients and medical practitioners, Dr Darbar added.

Listing the vital points- differences between AMA and TPA-governed public insurance companies —Dr Darbar said empanelment of the hospitals should not be restricted to a few favoured hospitals by the TPAs and insurance companies. It should be open to all qualified medical professionals who are registered with the Medical Council of India and with the local health authorities. The patients must have the right to choose any doctor or hospital.

Secondly, categorisation of hospitals which sign for PPN network must be done in a transparent manner and the clear guidelines drawn by the medical expert panel must be considered for categorisation, say AMA officials. “Cashless approval protocol must be made transparent and there should be no deductions and delays in payment. The approval process has to be supervised by company doctors who are appropriately qualified by MCI,” said Dr Pragnesh Vachchrajani, vicepresident of AMA, while listing the major points of mediclaim disagreements.

The hospitals which sign the MOU are categorised by the insurance companies under A, B C and D grades. Hospitals under A grade are offered Rs 45,500 for coronary angiogram; hospitals under B grade are offered Rs24,000; C grade hospitals are offered Rs21,000 while D grade hospitals are offered Rs16,000 for the same procedure.

“The criteria applied to grade the hospitals are not disclosed. To discuss the parameters and point of differences with the TPAs and insurance companies, AMA called their representatives thrice for meetings during April 1 to May 15 however, none of the invitees turned up for the meetings,” added Dr Vachhrajani.

Published in DNA on May 16, 2011

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