03/25/23 1

Management of Medical Adjudication of Claims

Dr Sachin Kasat
MBBS AIII FIII MBA (Finance) LLB 3rd year
kasatsa@hotmail.com
WhatsApp - 9421434485
 ADJUDICATION

Adding Judgement

03/25/23 3
Factors Affecting Cost

03/25/23 4
Before Knowing HOW… Need to Know What Type of Bills
Hospitals and Billing Patterns

BILLING PATTERNS
• In India, the Hospital bed per 1000 is 0.7 vs 5 per 1000
– LINE ITEM WISE
– PROCEDURE WISE as recommended by WHO
– PER DIEM WISE • The ratio of the density of beds in cities is about 4 times
– FULLY LOADED PACKAGES that of the rural areas, with Delhi & Mumbai being the
– OPEN BILLING highest

03/25/23 6
 What is to be done ?

Practical Steps – Common across ailments

03/25/23 7
9 Step Ladder Process

03/25/23 8
Common Diseases – Case Studies
Conservative

 Pyerexia ( Malaria, PUO, Dengue etc.)

 RTI (Covid 19, Pneumonia, Broncitis, Asthma)
 UTI  Need for hospitalisation
 AGE  Care Plan
 Gastritis  Diagnostic evidence
 Stroke  Execution as per Care Plan
 MI  LOS monitoring
 Chemotherapy  Billing

Surgical

 Cataract Diagnostic Evidence

 TKR.THR
 Fractures
 PTCA, CABG OT Notes

 Hysterectomy
 Septoplasty
 Appendicectomy / Cholecystectomy Operative Evidence

03/25/23 9
 Cost Containment > Overbilling and Abuse
In addition to field investigations, abuse has been reduced by use of the following Case Studies

 Databases of Procedures
Recovery Times
 Databases of Providers
 Databases of High End Drugs  COLI
 Databases of Implants  Hospital Type
Implants DB
 Definitions of Room Rent Inclusions  Comorbidity
 Health Index: benchmark Average payout for procedure  Complications
 Demographics of Patient
 Qualifications of Providers Case Study

Abuse Triggers

 Incidence Rates per Procedure per district Based on various triggers, a scoring
 Utilization per hospital per procedure pattern has been created.
 Physician Database & Utilization review of each physician
 Multiple hospitalizations of same family
 Incidence of Emergency hospitalizations Each hospitalization is scored

 More than 100% occupancy of hospitals

 LOS too high/low as per STGs
 Exceptions like complications/comorbidities beyond predefined target if found in suspicious category; full
 High incidence of infectious diseases in non endemic geographies fledged investigation is to be conducted

Strictly Private and Confidential

Indication for Dialysis
Acute renal Failure (ARF) Chronic Renal Failure(CRF)
 Severe fluid overload  Pericarditis
 Refractory hypertension  Fluid overload or pulmonary edema refractory to diuretics
 Uncontrollable hyperkalemia  Accelerated hypertension poorly responsive to antihypertensives
 Nausea, vomiting, poor appetite, gastritis with hemorrhage  Progressive uremic encephalopathy or neuropathy such as confusion,
 Lethargy, malaise, somnolence, stupor, coma, delirium, asterixis, myoclonus, wrist or foot drop, seizures
asterixis, tremor, seizures,  Bleeding diathesis attributable to uremia
 Pericarditis (risk of hemorrhage or tamponade)  
 bleeding diathesis (epistaxis, gastrointestinal (GI) bleeding and
etc.)
 Severe metabolic acidosis
 Blood urea nitrogen (BUN) > 70–100 mg/dl
 
Pre hospitalization documents Post discharge documents

• Clinical notes with planned line of • All investigation reports,Clinical notes/

management Indoor case papers

• Pathological Examination (Complete Blood

count, Blood urea, Serum Creatinine, GFR, • Detail discharge Summary & dialysis chart
serum electrolytes) all these investigations (Only dialysis chart in chronic dialysis pts)
to be repeated monthly.

 
• In chronic renal failure/ chronic dialysis
patients investigations need to be done
and submitted only once.
 
• Quarterly- Serum Iron, ferritin, TIBC, TSAT,
SGOT, SGPT, viral markers, calcium,
phosphate
Claims Cost Management

• Medical Mngt team : That would negotiate with hospitals on real time basis during Cashless Process

• LOS for Acute conditions and Conservative claims

• OP to IP Conversion claims
• Co-Morbidity claims : Std Package procedures
• Limiting use of Pharmacy on necessity basis

• Team Composition :
• Sr. MD. MBBS Drs. Clinical practice of 15 to 20 years
• MBBS drs with clinical practice of minimum 5 to 10 years
• Filed team for Hospital visit

• Provider n/w Team :

• That would pre negotiate Schedule of Charges for Cashless and Reimbursement claims
• Proper discounting on non Package procedures
• For Negotiating of advanced Technology Procedures ( Robotics )

Strictly Private and Confidential

Different Radiotherapy Treatment Plans

03/25/23 14
Different Radiotherapy Treatment

03/25/23 15
OPHTHALMOLOGY CASES
CATARACT SURGERY

03/25/23 17
ORTHOPEDIC CASES
ORTHO CASE
Case Reference Observation Detailed Study Report
Patient ABCDLMN admitted for PIVD L4-L5 with canal stenosis and received treatment in
form of Laminectomy L4-L5 canal decompression which is covered in package xxxxxxxx

Following document which impact adjudication decision are absent and not asked for

1)Conservative management before surgery is not provided.

2)Post operative care MRI report is not available.3

Surgery Not 3)Post-operative photo of patient with scar is available.

CASE/PS2/ required as per As per triggers. 1) Surgery done required as per MRI report.2) Patient residence is in
HOSP22P00555/ Care Plan and JANJGIR-CHAMPA but patient was admitted in
CK3046375 Diagnostic
Reports Raipur. As per case 1) Details of conservative management is not available hence there is
suspense for immediate need of surgery without undergoing conservative treatment.

2) Pre-operatve MRI dated 25/02/2020 shows Mild compression of the bilateral descending
nerve root with canal stenosis seen at L3-L4,L4-L5 level & central disc protrusion with
inferior migration.

3) Post operative x-ray dated 28/02/2020 showing laminectomy is done.

4) Post operative care plan given to patient includes only oral medicines.

03/25/23 19
Patient Admitted Once but Claimed Twice

Patient Date of
Case Id Diagnosis Name of surgery Remark
name surgery

Poly trauma ?
head injury & Closed reduction
CASE/PS3/
right femur elastic nailing right,
HOSP22P00555 13/11/2020
fracture tibia left left tibia & Right
/CK3413645
fibula fracture femur
right fibula

Patient admitted on 11/11/2020 & discharge on 15/11/2020 hence readmission for POP left
ABCDLLLLB lower limb tibia shaft not possible but as per admission register patient admitted for POP but
physically patient neither admitted in hospital nor POP tibia done in operation theater.

CASE/PS3/
Fracture tibia POP left lower limb
HOSP22P00555 18/11/2020
shaft left leg tibia shaft
/CK3420015

03/25/23 20
Patient Admitted Once but Claimed Twice

03/25/23 21
Patient Admitted Once but Claimed Twice

03/25/23 22
Case Study through Data Analytics Triggering Fraud of Hospital
Patient Surgery Surgery
Case Number Surgery
Name Date Time
CASE/PS2/HOSP22P00555/
30/08/2020 1:00 PM Laminectomy
CK3299515
CASE/PS2/HOSP22P00555/
30/08/2020 2:20 PM Laminectomy
CK3299521
CASE/PS2/HOSP22P00555/R3299519 30/08/2020 3:30 PM Laminectomy
CASE/PS2/HOSP22P00555/
30/08/2020 3:30 PM Laminectomy
CK3295929
CASE/PS2/HOSP22P00555/
30/08/2020 5:20 PM Laminectomy
CK3298668
CASE/PS2/HOSP22P00555/
30/08/2020 6:00 PM Laminectomy
CK3296435
CASE/PS2/HOSP22P00555/
30/08/2020 No Timing Given Arthroscopic removal of loose bodies
CK3299256
CASE/PS2/HOSP22P00555/R3299263 30/08/2020 No Timing Given Arthroscopic Meniscus Repair / Meniscectomy(SB036A)
CASE/PS2/HOSP22P00555/
30/08/2020 No Timing Given Arthroscopy / open - synovectomy(SB074CGA)
CK3299509
CASE/PS2/HOSP22P00555/
30/08/2020 No Timing Given Arthroscopy / open - synovectomy(SB074CGA)
CK3299246

These Surgeries are not possible to be done in few minutes

There is time for anesthetia, actual surgery, post anesthetia, OT Table cleaning

So data analytics on time of surgery helps to capture such fraud non conducted
surgeries documented as surgeries for making claims to insurance.

03/25/23 23
Arthroscopy / open - synovectomy, Arthroscopy - loose body removal,
Arthroscopic Meniscus Repair / Meniscectomy

03/25/23 24
Implant Removal under LA/ RA / GA
Fracture Surgeries

03/25/23 25
CLOSED REDUCTION V/S OPEN REDUCTION FOR FRACTURES

ORIF & CRIF

DETAILS

03/25/23 26
SURGICAL CASES
Appendicectomy
• Definition: Surgical removal of appendix

• Indications:
– Appendicitis- Acute/Chronic
– Appendicular perforation
– Appendicular abscess
– Suspected malignancy

• Surgery:
– Conventional with McBurney’s incision
– Laparoscopic Appendicectomy

• Pre-requisite:
– Clinical note
– CBC
– USG

• Post-op requirement:
– Histopathological examination report

03/25/23 28
Haemorrhoidectomy
• Definition: Surgical removal of prolapsed piles
• Grading:
– Grade 1 - bleed but do not prolapse
– Grade 2 - prolapse outside the anal canal but reduce spontaneously
– Grade 3 - prolapse outside the anal canal which requires manual reduction
– Grade 4 - irreducible and constantly prolapsed
• Indication:
– Required in 3rd-4th grade
– Required in 1st-2nd - according to symptoms
• Conventional surgery:
– Open excision with mucosa
– Close excision without mucosa
– Band ligation
– Staple ligation
– Sclerotherapy
• Pre-requisite:
– Clinical note

03/25/23 29
 QUESTIONS?

Dr Sachin Kasat
MBBS AIII FIII MBA (Finance) LLB 3rd year
kasatsa@hotmail.com
WhatsApp – 9421434485
Youtube: @drsachinkasat
https://www.youtube.com/channel/UCJApSNI99Qf7JZKeLicBNIA
03/25/23 30