ACKNOWLEDGEMENT FICCI is deepy indebted to the Heath Insurance Advisory Group for focussing on Heath Insurance Fraud as one of the areas of intervention. FICCI is especiay thankfu to the Working Group on for having conceptuaized and deveoped the Working Paper in a an extremey short span of time. We are particuary thankfu to the foowing peope for their unreenting and unabated support and co-operation: 1. Ms. Meena Kumari, Joint Director, IRDA 2. Mr Aam Singh, Assistant Managing Director, Miiman 3. Ms Mati Jaswa, Consutant, Project TPA GIPSA 4. Mr Jagbir Sodhi, Director, Swiss Re 5. Dr Somi Nagpa, Senior Heath Speciaist, Word Bank 6. Dr Praneet Kumar, Chairman, Technica Committee, NABH & CEO, BLK Super Speciaty Hospita 7. Dr C H Asrani, Chief Executive, X-Caim 8. Mr Shreeraj Deshpande, Head - Heath Insurance, Future Generai India Insurance Company Ltd 9. Mr Nazeem Khan, VP, ICICI Lombard
Content 1. Introduction............................................ 01 2. Defining Fraud & Abuse................................... 02 3. Managing Fraud........................................ 05 (A)Process improvements or modifications.................................. 05 (B)Industry Intervention................................................. 07 (C)Government or Reguatory Interventions................................. 11 ANNEXURES.............................................. 13 Annexure A:.......................................................... 13 Indian Pena System Code (IPC) and Indian Contract Act Annexure B:.......................................................... 14 USA Lega Framework Annexure C:.......................................................... 17 Extracts from IRDA Guideines on Fraud Annexure D: Commony use Figures and aert................................ 19 Annexure E:........................................................... 22 Intimation to insurer or TPA Annexure F:........................................................... 23 Education Annexure G........................................................... 26 Defining Leves of Misconduct/fraud and Potentia Responses Annexure H:......................................................... 32 Medica Counci of India Code of Ethics Annexure I............................................................ 35 Lega etter sampe
FICCI Heath Insurance Working Group Tacking Fraud in Heath Insurance 1.Introduction There is a growing concern among the insurance industry about the increasing incidence of abuse and fraud in heath insurance. FICCI sub group on heath insurance fraud was set up to deiberate upon the issue and come up with a working paper on heath insurance abuse and fraud management for the practitioners within the heath insurance industry and to suggest a framework of best practices. This paper is the resut of sub-groups efforts and deiberations over a short period of 12 weeks. The paper begins with definition of fraud and abuse, different parties invoved in various types of heath insurance fraud, triggers that represent possibe presence of abuse and fraud and the actions that coud be considered at various eves. The paper aso captures the issues concerning inadequate ega provisions and concerning code of conduct for medica practitioners. The ideas presented here can be categorised into one of three broad areas: Category Industry Considerations Time-frame to yied resuts Process improvements or Company specific, no industry Immediate modifications intervention Industry intervention Industry bodies endorsing, with Short/medium-term very itte reguatory or government intervention Government or reguatory Industry intervention insufficient Medium/ong-term intervention aone, reguatory or government intervention required After presentation of this initia working paper and receipt of feedback from wider community of a stakehoders, the FICCI sub group wi consider producing a more forma "white paper", incorporating concepts and further recommendations that are ikey to emerge from expanding the diaogue to more members of the industry, consumer bodies and providers. The aim of the white paper wi be to detai individua company eve actions, potentia industry eve actions and reguatory actions which can impact heath insurance fraud. 01
2. Defining Fraud & Abuse It is a matter of concern that 'insurance fraud' is not defined under the Indian Insurance Act. IRDA recenty quoted the definition provided by the Internationa Association of Insurance Supervisors (IAIS) which defines fraud as "an act or omission intended to gain dishonest or unawfu advantage for a party committing the fraud or for other reated parties." Other instruments within the Indian ega system, such as the Indian Pena Code (IPC) or Indian Contract Act, aso do not offer specific aws. Sections of the IPC which dea with issues of frauduent act, forgery, cheating etc. are sometimes appied but none of them are specificay targeted at insurance fraud and are inadequate for purpose of acting as an effective deterrent. In absence of specific aws and harsh punishments, prosecution wi rarey be successfu and if successfu, the penaty inadequate to deter others. As socia heath insurance grows the centra and state governments wi become one of the argest victims of heath insurance fraud and that may be the catayst that eads to the deveopment of a comprehensive ega framework to tacke heath insurance fraud. (More information about IPC, Contract Act and state and federa aws in the USA is presented in Annexure A & B) In simpe parance, insurance fraud can be defined as: The act of making a statement known to be fase and used to induce another party to issue a contract or pay a caim. This act must be wifu and deiberate, invove financia gain, done under fase pretences and is iega. 02 Heathcare fraud as defined by the Nationa Heath Care Anti-Fraud Association (USA): "The deiberate submitta of fase caims to private heath insurance pans and/or tax-funded pubic heath insurance programs." "Intentiona deception or misrepresentation that the individua or entity makes, knowing that the misrepresentation coud resut in some unauthorised benefit to the individua, or the entity, or to another party." Abuse can be defined as practices that are inconsistent with business ethics or medica practices and resut in an unnecessary cost to caims. The biing of services that may not be frauduent, but may be of margina utiity, are inconsistent with acceptabe business and/or medica practices, and are intended for the financia gain of a particuar individua or corporate can be cassified as abuse. Few exampes of common heath insurance abuse woud be - excessive diagnostic tests, extended LoS, conversion of day procedure to overnight admission, admission imited to diagnostic investigations etc.
Fraud is wifu and deiberate, invoves financia gain, done under fase pretense and is iega. Abuse generay fais to meet one or more of these criteria, hence the subte difference. Needess to say that the main purpose of both fraud and abuse is financia gain. Parties invoved in heath insurance fraud and types of fraud committed by each IRDA guideines cassify various insurance fraud as under: a) Poicyhoder Fraud and /or Caims Fraud - Fraud against the insurer in the purchase and/or execution of an insurance product, incuding fraud at the time of making a caim. b) Intermediary Fraud - Fraud perpetuated by an intermediary against the insurer and/or poicyhoders. c) Interna Fraud - Fraud / mis-appropriation against the insurer by a staff member. (Seect portions of IRDA circuar are presented in Annexure C) As reevant to heath insurance, the type of fraud committed by customer, intermediary - agent, broker, heathcare provider either individuay or jointy or in connivance with interna staff of insurance company/tpa vary in nature and modus operandi. Commony committed fraud by a customer of heath insurance reate to: conceaing pre-existing disease (PED) / chronic aiment, manipuating pre-poicy heath check-up findings fake / fabricated documents to meet poicy terms conditions, dupicate and infated bis, impersonation, participating in fraud rings, purchasing mutipe poicies, staged accidents and fake disabiity caims, The agents and brokers are usuay invoved in fraud reating to providing fake poicy to customer and siphoning off premium, manipuating pre-poicy heath check-up records, guiding customer to hide PED/materia fact to obtain cover or to fie caim, participating in fraud rings and faciitating poicies in fictitious names, channeising customers to rouge providers fudging data in group heath covers 03
Due to the absence of standard medica protocos, no oversight of a reguator, the provider induced fraud and abuse in India forms quite a arge portion of frauduent caims. It woud be quite difficut for a customer to fie a frauduent caim or fake medica documents without connivance of treating doctor or hospita. Provider reated fraud usuay pertain to: Overcharging, infated biing, biing for services not provided Unwarranted procedures, excessive investigations, expensive medicines, Unbunding and up coding Over utiisation, extended ength of stay Fudging records, patient history The empoyees of insurance company / TPA coud aso be invoved in committing fraud by expecting receiving favours / kickbacks, couding with other fraudsters / fraud rings, syphoning premium etc. a) Triggers One of the ways to contro fraud is to estabish triggers / red aerts for eary detection and corresponding action. A ist of commony used triggers and aerts for heath insurance caims are presented in Annexure D. These can be managed automaticay through systems capabiities or manuay detected through inspection of a physica fie. It shoud be noted that the presence of a risk management trigger ony warrants specia attention and further investigation of the caim to coect evidence is required. The exercising of a trigger is not proof of frauduent caim, ony an indication of possibe fraud. 04
3. Managing Fraud (A) Process improvements or modifications In this section, methods of identification, mitigation and management of fraud are considered within the context of process improvements or modifications that can be impemented by the insurer. Possibe areas to consider are set out beow. 1) Tee-underwriting or proposa verification ca: this shoud ideay be a centray controed process to ensure that the proposa form contents refect the poicyhoder's understanding and specificay incuding confirmation that no PEDs exist. This shoud be done after a proposa is received but before a poicy is issued. It heps to minimise agent-ed fraud and the use of recorded cas may hep substantiate evidence of fraud at caims stage. In addition, this ca can be utiised to confirm that the poicyhoder fuy understands the benefits and excusions of the poicy. Cost: ow for verification ca Compexity to deveop/administer: medium - agent needs to discose poicyhoder's contact number Working group output: a best practices note which insurers can utiise to create a standardised verification ca process. Underwriting is compex and a very companyspecific process, so no best practice or guideines wi be deveoped for this area 2) Pre-authorisation: this process is a vita component of the heath insurance caims system. It is the first eve check to curb fraud and capabe of eiminating or reducing the ikeihood of its occurrence. However, whether due to an insurer's processes and systems not being robust enough or ack of awareness on the part of customer or provider, this process is often not adhered to in the manner required and the key components of this process which make it effective, need to be impemented propery. a. Pre-authorisation requests for schedued surgeries must be submitted at east 24 hours before admission b. Impementation of the standardised pre-authorisation, discharge summary and biing format must be fast-tracked. 05
3) Intimation to insurer or TPA: the first intimation ca to the insurer or TPA is a very rich source of information about the status of the poicyhoder at time of admission. As a resut, this inteigence shoud be used in an optimum manner. The best practice in respect of what information shoud be sought at the intimation stage to mitigate fraud, shoud be documented and distributed. A sampe of the type of information that can be coected at this stage is provided in Annexure E. Cost: ow Compexity to deveop/administer: ow Working group output: A best practices note which insurers can utiise to streamine processes covering caim intimation and pre-authorisation. 4) Expanation of benefits: in some markets, insurers send the poicyhoder a detaied breakdown of what benefits they have paid for. This can be very effective way to check if any impersonation or biing for services not provided had occurred. Cost: ow Compexity to deveop/administer: ow Working group output: a best practice note which insurers can utiise to design a "Benefits Expanation" etter 5) Fraud detection toos and technoogy: insurers in advanced markets depoy robust technoogy and data anaytics processes for detecting outier behavior or for predictive modeing. These function as a kind of eary warning system for detecting fraud. The soutions offered can work in conjunction with existing practices to create a robust framework for eary detection / prevention of fraud. Cost: medium Compexity to deveop / administer: medium Working group output: to encourage and advocate that insurers depoy enabing technoogy 6) Whistebower poicy (company eve): deveop a reporting and rewards system that wi motivate individuas to aert an insurer about individua cases of fraud or systematic fraud. This can be a very attractive mechanism through which the genera popuation can be engaged in the fight against fraud. In addition this is a mechanism for disgrunted co-conspirators to exit a risky situation whist caiming credit for stopping it. 05
Cost: ni, ony based on outcome Compexity to deveop/administer: ow Working group output: to encourage and advocate that insurers deveop their whistebower poicy 7) "Name & shame" guideines: (company eve): pubicy discosing names of individuas and institutions invoved in a confirmed case of heath insurance fraud, especiay when a crimina or civi case has aready been fied is an effective way of raising community awareness that insurance fraud wi not be toerated. An interna media poicy about how and what to discose as we as in which situations, can provide vauabe guidance as the time to take such decisions is usuay short. Cost: ni Compexity to deveop/administer: medium, proper ega review of a information reeased is required to avoid accusations of ibe or sander Working group output: to encourage and advocate that insurers deveop their interna poicies (B) Industry Intervention As an industry evoves, certain systematic requirements emerge. These are generay intended to organise and structure the industry and are often best impemented by the industry through a coective body, such as Genera Insurance Counci (GIC) or through a ess forma forum specificay designed for such tasks. In recent few months, Genera Insurance Counci has taken initiative in fraud data sharing among member companies and has aso ooked at cassification, monitoring and deveoping tempates for data sharing; it is work-inprogress at the time of writing this paper. The data sharing shoud aso ead to coective action for effective deterrence, either through GI Counci or the recenty constituted Heath Insurance Forum. Key to the success of coective action wi be backisting / dis-empanement by a of those entities who are proven to induge in fraud and pursuing punitive action, recovery of money. Whie data sharing can be the start point, achievabe in a short time, the industry eve interventions need to be wide and deep for a encompassing impact. Some of the initiatives suggested beow are equay easy to achieve if industry woud set out the task. 07
1) Education: fraud can happen inadvertenty and due to ignorance. It is in the industry's interest to create education and awareness coatera that creates awareness about the impact of insurance fraud and its impications. This can be depoyed for a eves of insurance and TPA empoyees. It can incude content for consumer and provider education to create awareness and ensure that individuas are not inadvertenty faciitating fraud. Sampe messaging content is avaiabe in Annexure F. Cost: Low Compexity to deveop/administer: Low Working group output: initia recommendations with sampe content. 2) Contracting: in the absence of appropriate aw on insurance fraud, the industry shoud deveop mode causes for incorporation into poicy contract, in contract with providers, in agency/broker contracts etc. The definition of what constitutes fraud, what penaties and punitive actions woud foow upon confirmation of fraud coud be spet out ceary in the contract and caw back provisions for recovery of money into some of these contracts shoud be expored. 3) Deterrence guideines: industry recommendation on steps and processes an insurer can undertake when fraud is suspected and when it is confirmed. This woud provide a common framework or best practice on how to respond. Refer to Annexure F for different types of fraud/misconduct and corresponding action to be taken. It is to be noted that insurance industry has not made adequate use of Medica Counci of India (MCI) guideines on code of conduct and ethics for medica practitioners. The effective deterrence for medica fraternity can ony come from medica reguator, in the absence of which the good offices of MCI can be utiised. Annexure H provides a ist of MCI provisions which coud be invoked against specific misconduct. 08 Cost: ni Compexity to deveop / administer: ow Working group output: sampe interna deterrence guideines and other content to assist insurers. 4) Benchmarks: the industry coud coaborate with IIB to create benchmarks that individua stakehoders can utiise to obtain better insight into their overa performance. A proven approach in this direction is to aggregate a industry data in
a singe data warehouse and then deveop various benchmarks that an individua insurer can compare itsef with. Naturay, these benchmarks need to be deveoped carefuy so that the comparison is on a ike-for-ike basis. Cost: medium (one time and ongoing) Compexity to deveop/administer: medium Working group output: a sma sub-set of the working group can engage with IIB to hep define those benchmarks which the industry requires and which the existing reported data supports. 5) Medica protocos and treatment guideines: the industry shoud advocate for the deveopment and dissemination of independent 3rd party evidence based standard medica protocos and treatment guideines. 6) Provider biing ID and registration porta: a version of this contro mechanism has been very effective in curbing rampant fraud amongst providers of durabe medica equipment to Medicare beneficiaries in the US. The Genera Insurance Counci or newy constituted Heath Forum shoud buid a provider registration porta. This porta wi be used by providers to enter their detais (simiar to the one in an empanement form.) After verification of the detais entered by the providers by any one TPA, their detais wi be added to the common database and a unique provider ID wi be issued to the provider. For providers not currenty empaneed by any TPA or insurer, their detais wi need to be verified before issuance of a unique ID. This unique ID (coud be the same as proposed by IRDA) woud aso act as a biing ID and woud be mandatory on a caim forms. In cases of fraud, a provider wi risk osing its biing ID thus incapacitating it from odging any caims. Naturay, the industry woud need to maintain a common and accessibe database which can verify a biing IDs in rea time. Individua doctors aready have a registration ID and the pre-authorisation and caims forms seek this ID. The industry needs to insist that this number be provided for more active profiing of individua doctors. Cost: ow/medium Compexity to deveop/administer: ow Working group output: a sma sub-set of the working group can provide guidance to the entity seected to deveop the provider biing ID and registration porta 09
7) Watch ist creation and maintenance: A TPAs and insurers maintain and share their own ists of backisted providers. Some insurers and TPAs share such ists of providers, refer Annexure F. A common isting of these entities by coecting this information from a TPAs and insurers woud benefit the industry as a shared knowedge repository. The deveopment of such a repository woud invove a "onetime" effort to coect existing backists from TPAs and insurers and then compie them into user-friendy format and an "on-going" effort to maintain it. Such a watch ist woud resembe a website with a secure password restricted area which woud contain indexed watch ists of individuas and corporate entities which have previousy defrauded or abused the insurance system. This woud be a centraised resource which insurers and TPA can assess and search and update. The credibiity of the data wi be enhanced by repacing an ad-hoc sharing of individua ists provided between insurers. Cost: ow Compexity to deveop/administer: ow/medium Working group output: a sma sub-set of the working group can provide guidance to the entity seected to deveop the website 8) Fraud investigator training program: a structured training program aong with mandatory examination, as we as continuing education requirements shoud be deveoped for fraud investigators. A fraud investigators must meet a minimum ski set requirement. In addition, there shoud be a mechanism whereby a fraud investigator can be assessed and certified for higher ski eves. This woud create a cadre of professiona and highy skied fraud investigators. It may be desirabe to ensure that these investigators are icensed by the IRDA. Cost: ow Compexity to deveop/administer: ow/medium 10 Working group output: a sma sub-set of the working group can iaise with IRDA or appointed institutions (e.g. NIA, III) to design the syabus of such a training program. The fu content, deivery mechanisms and examination modaities woud then be deveoped by that institution. 9) Whistebower system & rewards: (industry eve): in case of actionabe information about arger and more systematic fraud cases which span across entities, the industry (through IRDA or GIC or the newy formed Heath Insurance Forum) may wish to coordinate a reward program. Modaities of reward programs initiated by insurers as we as other government entities, such as tax or customs departments, might need to be studied.
Cost: ni, ony based on outcome Compexity to deveop/administer: medium Working group output: can provide guidance on how to maintain consistency with the whistebower poicies that individua insurers are impementing 10) Capacity and awareness deveopment in poice and prosecution agencies: in conjunction with buiding a cadre of fraud investigators, the industry wi need to invest resources in training poice and pubic prosecutors. Poice officers are not famiiar with intricacies of insurance processes and that can hinder progress in fraud investigations. Simiary, pubic prosecutors need requisite insurance knowedge to effectivey prosecute offenders. A training program for poice economic offence investigators and prosecutors coud be conducted by the same entity tasked with training fraud investigators. 11) Autonomous anti-fraud bureau: industry, reguatory and government bodies shoud support the creation of an independent anti-fraud bureau. Assistance to design organisationa structure, charter, funding mechanisms and operations can be sought from Coaition Against Insurance Fraud (CAIF) and Nationa Heathcare Anti-fraud Association (NHCAA). Focus activities can incude anti-fraud advocacy, pubic awareness, dissemination of best practices, education (e.g. case studies, training), centraised services (e.g. fraud hotine, data warehousing.) (C) Government or Reguatory Interventions 1) Reguatory action against icensed bodies: IRDA's jurisdiction spans insurers, agents, brokers and TPAs. Whie these entities are governed by detaied guideines, reguations and are subjected to reguar inspections/audits by Reguator, the action and penaty upon confirmation of connivance or active invovement in frauduent activity shoud aso be ceary spent out, eading to suspension/revocation of icense. Unfortunatey there is no equivaent reguator for the supervision of providers, which puts the onus on the Heath Forum to take coective action against providers induging in heath insurance fraud. It is aso necessary that MCI and Ministry of Heath pay an active roe in bringing frauduent hospitas and doctors to account. The Heath Forum shoud aso make a concerted effort to address these issues with members from the provider space. 11
2) Specific aws against insurance fraud: many countries have very specific aws against insurance fraud and occasionay more specific aws pertaining to socia insurance fraud. The specific aws can contain causes which ensure speedy resoution of cases, thus enhancing the impact of the aw. Since some of the vioators might be icensed entities, IRDA may aso need to review its reguations. 3) Introduction of caw back provisions: insurance fraud aws which contain provisions which enabe an insurer to recover payments, if fraud is proven subsequenty. These have been found to be very effective in other countries. Usuay such "caw back" provisions are imited to a certain time period, i.e. 3 or 5 years. 4) Reguatory requirements for specific anti-fraud units and capabiities in insurers: the icensing and inspection reguations of various insurance reguators aow them to seek detaied information about an insurer's anti-fraud capabiities. Insurers who do not demonstrate adequate safeguards may be fined. The recent guideines by IRDA aso require this (refer Annexure B) a) The corporate governance guideines mandate insurance companies to set up a risk management committee to ay down Risk Management Strategy. b) Discosing the adequacy of systems in pace to safeguard the assets for preventing and detecting fraud and other irreguarities on an annua basis. Further the guideines aso mandate each insurer to have fraud contro poicy approved by Board, to be reviewed annuay. The poicy is supposed to ay framework for fraud management department, cassification of potentia areas of fraud, information sharing mechanism, due diigence etc. 5) Anti-fraud pubic messaging: the reguator and government can coectivey undertake pubic messaging which highights the impact (higher premiums) and consequences (ega action) of insurance fraud. Such campaigns are generay panned as ongoing initiatives which are further enforced by "name & shame" initiatives. IRDA has run number of campaigns on poicy hoder education, insurance iteracy. Anti-fraud awareness campaigns coud form part of IRDA's consumer awareness campaigns. 12
ANNEXURES ANNEXURE A Indian Pena System Code (IPC) and Indian Contract Act "Section 23 and 24: utiises the term "wrongfu gain" - whie this may seem reevant, the working group does not fee that reiance on this section is hepfu Section 25: a person is said to act frauduenty if he acts with the intent to defraud but not otherwise. The working group fees this section is stronger than 23 and 24; however compainant shoud be aware that a court may ask the insurer to prove frauduent intent, which is often very difficut. The defendant may maintain it was an oversight, they did not know it was significant, or that someone ese competed the form on their behaf Section 463: reates to forgery and the working group fees that this is reevant for heath insurance fraud. "Whoever makes any fase documents or fase eectronic record or part of a document or eectronic record, with intent to cause damage or injury, to the pubic or to any person, or to support any caim or tite, or to cause any person to part with property, or to enter into any express or impied contract, or with intent to commit fraud or that fraud may be committed, commits forgery." Section 477 A: reates to fasification of accounts. This may be an appicabe section in some cases of heath insurance fraud. "Whoever, being a cerk, officer or servant or empoyed or acting in capacity of a cerk, officer or servant, wifuy and with intent to defraud, destroys, aters, mutiates or fasifies any book, eectronic record, paper, writing], vauabe security or account which beongs to or is in the possession of his empoyer or has been received by him for on behaf of his empoyer or wifuy, and with intent to defraud, makes or abets the making of any fase entry in, or omits or aters or abets the omission or ateration of any materia particuar from or in, any such book, eectronic record, paper, writing] vauabe security or account, sha be punished with imprisonment of either description for a term which may extend to seven years, or with fine, or with both." Appicabiity of Section 17 in The Indian Contract Act, 1872 "Fraud" means and incudes any of the foowing acts committed by a party to a contract, or with his connivance, or by his agent, with intent to deceive another party thereto of his agent, or to induce him to enter into the contract:- vthe suggestion, as a fact, of that which is not true, by one who does not beieve it to be true (across entities) vthe active conceament of a fact by one having knowedge or beief of the fact (across entities) va promise made without any intention of performing it (intermediary/ saes staff) vany other act fitted to deceive (across entities) vany such act or omission as the aw speciay decares to be frauduent 13
ANNEXURE B USA Lega Framework In the US, heath insurance fraud can be prosecuted under federa aws or state aws. The Heath Insurance Portabiity and Accountabiity Act of 1996 (HIPAA) makes heath care fraud a federa crime. Heath care fraud occurs when anyone knowingy and wifuy executes, or attempts to execute, a scheme to defraud any heath care benefit program in connection with the deivery of or payment for heath care benefits, or obtains any property of the heath care benefit program by fase representations. A person who vioates the statute may be fined, imprisoned up to 10 years, or both. If the fraud resuts in injury to a patient, he may be imprisoned up to 20 years. If death resuts, he may be imprisoned for ife (18 U.S.C. 1347). The statute appies to fraud against private insurance companies and government heath care programs. It aso appies to any insurance program invoving medica payments (e.g. heath insurance, automobie insurance, workers' compensation) (18 U.S.C. 24). HIPAA aso prohibits knowingy and wifuy fasifying, conceaing, or covering up a materia fact; or making a fase statement; or using or making any fase or frauduent document in connection with the deivery of or payment for heath care benefits or services. A person who vioates this aw may be fined, imprisoned up to five years, or both (47 U.S.C. 1035). Fase Caims A person who knowingy presents a frauduent caim to the U.S. government (e.g. Medicare) is fined between $5,000 and $10,000 pus trebe damages (three times the government's osses) under the federa Fase Caims Act (31 U.S.C. 3729). Fase Statements 14 A person who knowingy and wifuy fasifies, conceas, or covers up a materia fact; makes a fase statement; or uses or makes a fase or frauduent statement to a government agency is fined, imprisoned up to five years, or both under the federa Fase Statements to a Government Agency aw (18 U.S.C. 1001). Mai Fraud A person who engages in a scheme to defraud any person that invoves the use of the U.S. mai may be fined, imprisoned up to 20 years, or both. If the attempt to defraud affects a financia institution (e.g. bank or credit union), the person may be fined up to $1,000,000, imprisoned up to 30 years, or both (18 U.S.C. 1341). Maiing a frauduent caim vioates this statute.
Wire Fraud A person who uses an interstate wire transmission (e.g. teephone, automated caim system) to carry out a frauduent scheme may be fined, imprisoned up to 20 years, or both. If the attempt to defraud affects a financia institution (e.g., bank or credit union), the person may be fined up to $1,000,000, imprisoned up to 30 years, or both (18 U.S.C. 1343). Racketeer Infuenced and Corrupt Organization Act (RICO) Under RICO, crimina charges and civi awsuits can be brought against a person engaged in a "pattern of racketeering activity." Racketeering activity incudes mai or wire fraud. Submitting a number of frauduent insurance caims over a period of time woud constitute a "pattern" of racketeering. Crimina penaties incude a fine, imprisonment up to 20 years (or more in certain circumstances), or both and forfeiture of any proceeds gained from the racketeering activity (18 U.S.C. 1693). Civi remedies incude trebe damages, meaning an insurer coud coect punitive damages equa to three times their actua osses, and reasonabe attorney fees (18 U.S.C. 1964). The appicabe state aws are: Most states have statutes regarding fraud and some specificay address insurance fraud. Insurance fraud statutes generay define what constitutes fraud and what penaties or damages may be imposed. Both the Nationa Conference of Insurance Legisators (NCOIL) and the Nationa Association of Insurance Commissioners (NAIC) have insurance fraud mode acts. NCOIL's mode act incudes crimina penaties, restitution, administrative penaties, and civi remedies for insurance fraud. NAIC's mode requires fraud warnings on insurance appications and caim forms, fraud reporting by insurers, the creation of fraud units within insurance departments, insurer anti-fraud initiatives, and penaties. Usuay the States define insurance fraud as a cass D feony. For exampe, in Connecticut, a person is guity of insurance fraud when, with the intent to injure, defraud, or deceive any insurance company, he knowingy presents fase, incompete, or miseading information in support of an insurance appication, caim, or other benefit. This subjects a person to a fine up to $5,000, up to five years imprisonment, or both (C.G.S. 53a-215). 15
Larceny Penaties Larceny Degree Property Invoved Cassification Penaty First Over $10,000 Cass B feony Up to 20 years prison; up to $15,000 fine; or both Second Over $5,000 Cass C feony Up to 10 years prison; up to $10,000 fine; or both Third Over $1,000 Cass D feony Up to 5 years prison; up to $5,000 fine; or both Fourth Over $500 Cass A misdemeanor Up to 1 year prison; up to $2,000 fine; or both Fifth Over $250 Cass B misdemeanor Up to 6 months prison; up to $1,000 fine; or both Sixth $250 or ess Cass C misdemeanor Up to 3 months prison; up to $500 fine; or both Source: http://www.cga.ct.gov/2005/rpt/2005-r-0025.htm 16
ANNEXURE C Extracts from IRDA Guideines on Fraud Re.: Fraud Detection, Cassification, Monitoring and Reporting by Insurers The Authority has taken a number of measures to address the various risks faced by the insurance companies. Some of these incude: The Corporate Governance guideines mandate insurance companies to set up a Risk Management Committee to ay down Risk Management Strategy. As part of the Responsibiity Statement which forms part of the Management Report fied with the Authority under the IRDA (Preparation of Financia Statements and Auditors' Report of Insurance Companies) Reguations, 2002, Management of the insurance company discoses the adequacy of systems in pace to safeguard the assets for preventing and detecting fraud and other irreguarities, on an annua basis. The Guideines mandate insurance companies to put in pace, as part of their corporate governance structure, fraud detection and mitigation measures and submit periodic reports to the Authority in the formats prescribed herein. 1. Anti-Fraud Poicy: A insurance companies are required to have in pace the Anti-Fraud Poicy duy approved by the Board. The poicy sha duy recognise the principe of proportionaity and refect the nature, scae and compexity of the business of specific insurers and risks to which they are exposed. It shoud consider reevant factors ike organisationa structure, insurance products offered, technoogy used, market conditions etc. As fraud can be perpetrated by cousion invoving more than one party, insurer shoud adopt a hoistic approach to adequatey identify, measure, contro and monitor fraud risk and accordingy, ay down appropriate risk management poicies and procedures across the organisation. The Board sha review the Anti-Fraud Poicy on an annua basis. The anti-fraud poicy sha broady cover the foowing aspects: i. Fraud Monitoring Department: Set-up a Fraud Monitoring Department (FMD) with we-defined procedures to identify, detect, investigate and report the fraud. A Compiance Officer sha be designated for this purpose, having direct access to the Board of the company. ii. Potentia Areas of Fraud: Identify areas of business and the specific departments of the organisation that are potentiay prone to insurance fraud and ay down a detaied area-wise/ department-wise, anti-fraud procedures, risk prevention and mitigation measures 17
iii. iv. Co-ordination with Law Enforcement Agencies: Lay down procedures to coordinate with aw enforcement agencies for reporting fraud and foow-up processes thereon. Framework for Exchange of Information: Lay down procedures for exchange of necessary information on fraud, amongst a insurers through respective councis. v. Due Diigence: Lay down procedures to carry out the due diigence on the personne (management, officers and staff) before appointment. vi. Reguar Communication Channes: Generate fraud mitigation communication within the organisation at periodic intervas and ay down appropriate framework for a strong whiste bower poicy. The insurer sha formaise the information fow from/amongst the various operating departments to FMD. 2. Fraud Monitoring Department (FMD) (Roe and Functions): The FMD sha have in pace reporting procedures from the various departments ike underwriting, caims, information technoogy, investments, accounts, interna audit and intermediaries departments. A personne sha be encouraged to report suspicious instances/ fraud to the FMD. The FMD sha aso ay down the poicy framework for the training of personne and intermediaries to sensitize them on prevention, detection, and mitigation of fraud. Suitabe cause shoud be incuded in the terms of appointment of empoyees/intermediaries that carifies the impications of fraud and pena provisions thereon. The head of the FMD sha be responsibe for furnishing various reports on fraud to the Authority. 3. Reports to IRDA: Statistics on various frauduent cases and action taken thereon aong with a Compiance Certificate duy signed by the Chief Executive Officer/Managing Director sha be fied with the Authority in form FMR 1 and FMR 2 every year within 30 days of cose of the financia year. 18 4. Reports to the Board: FMD shoud ay down appropriate framework for information to be submitted to the Board. The Board sha review the same periodicay. 5. Preventive mechanism: The Insurer sha inform both potentia cients and existing cients about their anti-fraud poicies. The Insurer sha appropriatey incude necessary caution in the insurance contracts/ reevant documents, duy highighting the consequences of submitting a fase statement and/or incompete statement, for the benefit of the poicyhoder, caimant and the beneficiary.
ANNEXURE D Poicy and caim history triggers 1. Caims from a poicy with ony one member at minimum sum insured amount 2. Mutipe caims with repeated hospitaisation (under a specific poicy at different hospitas or at one hospita of one member of famiy and different hospitas for other members of famiy), mutipe caims towards the end of poicy period, cose proximity of caims 3. Caims made immediatey after a poicy sum insured enhancement 4. Caims from a member with history of frequent change of insurer or gap in previous insurance poicy 5. Caims for poicy with evidence of significant over/under insurance as compared to insured's income/ife stye 6. Caims from a non-traceabe person or where courier/cheque have been returned from insured's documented address 7. Second caim in the same year for an acute medica iness/surgica minor iness/orthopedic minor iness in the same poicy period for main caim. Young maes between 25-35 years getting admitted for acute medica iness 8. Caims from members with no caim free years, i.e. reguar caim history Provider ocation or profie triggers 9. Caims from a hospita ocated far away from insured's residence, pharmacy bis away from hospita/residence 10. Caims for hospitaisation at a hospita aready identified on a "watch" ist or back isted hospita 11. Caims on hospita stationery without andine phone number, registration number, area pin code or doctor's quaification stated 12. Caims submitted that cause suspicion due to format or content that ooks "too perfect" in order. Pharmacy bis in chronoogica/running seria number or caim documents with coor photocopies. Perfect caim fie with a criteria fufied with no deficiencies 13. Caims with visibe tempering of documents, overwriting in diagnosis/treatment papers, discharge summary, bis etc. Same handwriting and fow in a documents from first prescription to admission to discharge. X-ray pates without date and side printed. Bis generated on a "Word" document or documents without proper signature, name and stamp. 19
14. Caims without supporting pre-post hospitaisation papers/bis 15. Caims with apparent discrepancy in diagnosis and ine of treatment: irreevant investigations for a particuar aiment, mismatch in ICD and CPT code/ procedure description, ine of treatment/procedure inconsistent with insured's profie/gender/age or season. Inconsistency between speciaisation of treating doctor and iness 16. Caims with incompete/poor medica history - compaints/presenting symptoms not mentioned, ony ine of treatment given, supporting documentation vague or insufficient 17. Caims without signature of the insured on pre-authorisation form 18. Reimbursement caim from a network hospita 19. Caims with missing information ike post-operative histopathoogy reports, surgica / anaesthetist notes missing in surgica cases 20. Caims with simiar format/pattern/cinica detais in discharge card/bi from a particuar provider Diagnosis or surgery-specific triggers 21. Caims for hospitaisation due to chronic/ife stye diseases management 22. Caims with LoS far in excess of average LoS for a particuar aiment 23. Caims reating to infertiity, abortion, miscarriage etc. 24. Caims for medica management admission for exacty 24 hours to cover OP treatment, expensive investigations 25. Caims for acute medica Iness which are uncommon e.g. encephaitis, cerebra maaria, monkey bite etc. 26. Caims for surgica conditions being treated conservativey 20 27. Caims for orthopedic iness being managed conservativey; accidents mandating treatment for hip, knee, anke, shouder, ebow and wrist joint 28. Caims for medica conditions being managed surgicay in the first year of the poicy - potentia indication for PED. e.g. iver disorder in first year of poicy 29. Caims where the cinica findings do not correate with chief compaints or diagnosis or ine of treatment; exaggeration of cassica cinica findings to portray severity in acute medica iness/minor surgica conditions 30. Caims with unjustified admission in ICU or use of genera anesthesia or assistant surgeon in a minor compexity or mid severity of condition
31. Caims with surgica treatment for face, nose, ear or other exposed body parts - indication of cosmetic surgery Biing and tariff based triggers 32. Caims where the cost of treatment is much higher than expected for underying etioogy 33. Caims with a reativey high proportion of pharmacy costs or physician fees (more than 50% of the tota caim vaue) 34. High vaue caim from a sma hospita/nursing home, particuary in cass B or C cities not consistent with aiment and/or provider profie 35. Caims with no intimation of caim ti submission of caim documents; deayed preauthorisation request sent after second day of hospita admission or extraordinary deay in reporting of caim; caim intimation on weekend or pubic hoidays especiay for pre-authorisation cases. Member based triggers 36. Caims from members creating abnorma pressure to sette caim; unusuay high knowedge of poicy terms, caim process, medica terminoogy or eagerness to negotiate caim amount 37. Caims where member is unwiing to meet face to face or does not provide phone number in the caim form. Caims from members where attitude is evasive, hostie, uncooperative, compaining 21
22 ANNEXURE E Intimation to insurer or TPA At various stages, ranging from pre-admission to post discharge, an insurer may engage with a poicyhoder (or attendee) and the provider. Each of these stages provides an opportunity to soicit and capture additiona information. This section detais the various stages and defines what information can be captured at each stage. 1) Pre-Auth request regarding emergency hospitaisation from the hospita Tee ca at the time of admission (to hospita) "Patient's vita statistics? i.e. puse, BP, respiratory, saturation Genera condition? - most woud say poor; eaborate by asking using cinica anguage What has prompted hospitaisation? - if objective parameters given such as ow pateets, high WBC, dengue positive then possibiity of fraud is ower; if more subjective terms used, may suspect abuse Who has been treating the patient for the aiment prior to now? - if no one and this is the first hospitaisation episode, consutation, chances of fraud/ abuse high Name and speciaty of doctor under whom patient is to be hospitaised? - is (s)he empoyed by hospita or visiting consutant? 2) A ca to patient after hospitaisation (medica) Diagnosis / suspected diagnosis given Room number and cass of room (e.g. singe, deuxe) Approximate estimate given (LoS, cost of care) 3) A ca to patient for potentia surgery Since when diagnosed? How was the diagnosis arrived at? (e.g. X-ray, sonography, MRI, biopsy) Since when were symptoms present? Approximate estimate given (LoS, cost of care)? Room number and cass of room (e.g. singe, deuxe) 4) A ca to hospita for potentia hospitaisation for surgery Duration since diagnosis given? How was the diagnosis arrived at? (X-ray, sonography, MRI, biopsy) Since when were symptoms present? Since when has the operating surgeon been treating the patient? Approximate estimate given (of LoS, cost of care)?
ANNEXURE F Education Potentia messaging for a consumer oriented "Dos" and "Don'ts" campaign Do's 1. Aways decare compete and accurate heath history on proposa form 2. Any suggestion to ater history by agent or any intermediary shoud be reported to the insurance company or centraised fraud hotine 3. Any person offering to manage medica reports at pre-poicy stage shoud be reported to the insurance company or centraised fraud hotine 4. Any person guiding you to forge or increase bis for genuine treatment shoud be reported to the insurance company or centraised fraud hotine 5. Any suggestion to ater disease in favor of caim by agent or any other intermediary or service provider shoud be reported to the insurance company or centraised fraud hotine 6. Any suggestion to fasify caim of heath / PTD/ death / convert OPD treatment to IPD treatment by agent or any other intermediary or service provider shoud be reported to the insurance company or centraised fraud hotine 7. Aways check your fina bi when taking cashess and sign it without fai Dont's 8. Never hide PEDs when competing proposa form 9. Do not attempt to manage medica reports at pre-poicy stage 10. Never attempt to infate bis for genuine treatment as it may ead to the entire caim being denied and resut in crimina proceedings 11. Refrain from manipuating aiment in an effort to seek coverage not entited to. Typicay intermediaries may tempt insured to mask an excuded aiment as a egitimate caim, e.g. undergoing hernia in first two years of excusion phase and caiming as acute abdomen or appendectomy 12. Never offer your insurance card to a non-beneficiary to caim treatment under your card 13. Do not sign on bank documents, e.g. proposa form, cashess authorisation form or fina bis 23
14. Never accept any offer to fabricate or exaggerate caims however tempting it may be Potentia content for agent education Do's 15. Aways ensure that the customer decares compete and accurate heath history on proposa form 16. Any suggestion to ater history by customer or any other person shoud be reported to the insurance company or centraised fraud hotine 17. Any person offering to manage medica reports at pre poicy stage shoud be reported to the insurance company or centraised fraud hotine 18. Any person asking to forge or infate bis for genuine treatment shoud be reported to the insurance company or centraised fraud hotine 19. Any suggestion to ater disease in favor of caim by customer or any other intermediary or service provider shoud be reported to the insurance company or centraised fraud hotine 20. Any suggestion to dishonesty fie caim for heath, PTD, death, or convert OPD treatment to IPD treatment by customer or any other intermediary or service provider, shoud be reported to the insurance company or centraised fraud hotine Dont's 21. Never hide PED or guide any insured to hide PED in proposa form 22. Never provide fase dupicate poicy copy to insured 23. Never faciitate any frauduent caim 24. Never attempt to manage medica reports at pre-poicy stage Potentia content for provider education Providers are an integra part of the muti-stakehoder insurance industry and pay key roe across the entire business chain. Providers are empaneed with trust by the insurer and bound by a mutua and egay binding contract. However, there are cases of mapractice committed by providers which directy confict with the insurer's interest. These sensitivities need to be understood and addressed by each provider when deaing with insured patients: 24
A robust code of high ethica practice needs to be foowed by a providers. Areas of particuar concern to insurers incude: 1. Biing for high cost medicine whie using generic or ow cost brands 2. Excessive and unwanted tests, investigations and procedures being conducted 3. Biing for extra number of physician visits not conducted or having extra visits when not required 4. Unbunding of procedures and biing them separatey 5. Increase in ength of stay either backwards or forwards without the knowedge of the customer 6. Upgrading the accommodation category for no reason of medica necessity. This incudes keeping a medicay stabe patient in ICU or ICCU 7. Origina and factua history of insured mis-represented and suppression of information to gain advantage 8. Refrain from putting up any caim on behaf of any customer without his knowedge for monetary benefit 9. Refrain from converting OPD treatment into IPD treatment for monetary benefit. 10. Refrain from any nexuses or cousion to produce fase or artificiay infated caims Any of the above scenarios if faced or observed in the ecosystem one shoud be reported to the insurance company or centraised fraud hotine 25
ANNEXURE G Defining Leves of Misconduct/fraud and Potentia Responses 1. Customer- occasionay the customer is the perpetrator of the fraud. Customer fraud are generay soft in nature, uness the customer is a professiona caimant who reguary submits fase caims. (a) Misconduct - Fase or suppressed history at proposa stage to hide PED and secure coverage. Action 1 - Poicy canceation for hiding materia fact, without refund of premium Action 2 - Sharing info to industry to backist customer at common database (b) Misconduct - Managing medica reports at proposa stage for gaining cover or reducing premium. Action 1 - Poicy canceation for hiding materia fact, without refund of premium Action 2 - Sharing info to industry to backist customer at common database (c) Misconduct - Infating bis manuay for genuine treatment. Action 1 - Poicy canceation for hiding intentiona misrepresentation, without refund of premium Action 2 - Sharing information with industry backist Action 3 - Add to name and shame ist Action 4 - Lega remedy, such as FIR on insured 26 (d) Misconduct - Manipuating aiment for seeking coverage not entited to, for exampe an excuded aiment is masked as egitimate caim (undergoing hernia in 1st two years of excusion phase and caiming as acute abdomen or appendectomy). Action 1 - Poicy canceation for hiding intentiona misrepresentation, without refund of premium Action 2 - Sharing information with industry backist Action 3 - Add to name and shame ist Action 4 - Lega remedy, such as FIR on both doctor and insured
(e) Misconduct - Getting non beneficiary treated under the poicy and caimed for sef by customer. Action 1 - Poicy canceation for hiding intentiona misrepresentation, without refund of premium Action 2 - Sharing information with industry backist Action 3 - Add to name and shame ist Action 4 - Lega remedy, such as FIR on both doctor and insured (f) Misconduct - Couding with provider (hospita) for converting OP to IP caim. Action 1 - Poicy canceation for hiding intentiona misrepresentation, without refund of premium Action 2 - Sharing information with industry backist Action 3 - Add too name and shame ist Action 4 - Lega remedy, such as FIR on both doctor and insured (g) Misconduct - Couding with provider for fake caim documentation. Action 1 - poicy canceation for hiding intentiona misrepresentation, without refund of premium Action 2 - Sharing information with industry backist Action 3 - Add to name and shame ist Action 4 - Lega remedy, such as FIR on both doctor and insured (h) Misconduct - Fake PTD caim. Action 1 - Poicy canceation for hiding intentiona misrepresentation, without refund of premium Action 2 - Deist from future PA coverage eigibiity Action 3 - Add to name and shame ist Action 4 - Lega remedy, such as FIR on both doctor and insured (i) Misconduct - Manipuated death caim by caimant. Action 1 - Poicy canceation for hiding intentiona misrepresentation, without refund of premium 27
Action 2 - Deist from future PA coverage eigibiity Action 3 - Add to name and shame ist Action 4 - Lega remedy, such as FIR on both doctor and insured 2. Provider - empaneed network provider are have different fraud patterns than nonnetwork hospitas. Whereas the non-network hospitas do not directy receive payments from hospitas and they may hep a poicy hoder in odging a fase caim, the empaneed providers are direct recipients of caimed amount thus the fraud they induge in is different. (a) Misconduct - Infation in caim cost by various methods (i) Misconduct - Substituting ow cost medicine with high cost brands Action 1 - Warning with temporary suspension for 3 months from network Action 2 - Pan-industry suspension (ii) Misconduct - Getting unnecessary/ unwanted tests done Action 1 - Warning with temporary suspension for 3 months from network Action 2 - Pan-industry suspension (iii) Misconduct - Biing extra number of physician visits Action 1 - Warning with temporary suspension for 3 months from network Action 2 - Pan-industry suspension (iv) Misconduct - Unbunding of procedures and biing them separatey Action 1 - Warning with temporary suspension for 3 months from network Action 2 - Pan-industry suspension (v) Misconduct - Increase in ength of stay, either pre or post admission, without the knowedge of the customer Action 1 - Warning with temporary suspension for 3 months from network 28
Action 2 - Pan-industry suspension (vi) Misconduct - Upgrading the accommodation category Action 1 - Warning with temporary suspension for 3 months from network Action 2 - Pan-industry suspension (b) Misconduct - Hiding PED aiment Action 1 - Warning with temporary suspension for 1yr from network Action 2 - Pan-industry suspension (c) Misconduct - Lodging fake caim without customer knowedge based on previous card detais Action 1 - Permanent de-panement Action 2 - Pan-industry backisting Action 3 - Add to name and shame ist Action 4 - Lega remedy, such as FIR on provider (d) Misconduct - Couding with agent or corporate group to have a set of insured for odging fake caims. Action 1 - Permanent dis-empanement Action 2 - Pan-industry backisting Action 3 - Add to name and shame ist Action 4 - Lega remedy, such as FIR on provider (e) Misconduct - Offering free OPD to customers with insurance cards and ater odging fake caims on their behaf. Action 1 - Permanent dis-empanement Action 2 - Pan-industry backisting Action 3 - Add to name and shame ist Action 4 - Lega remedy, such as FIR on provider 3. Provider - non-network providers do not receive a direct payment from the insurer so fraud perpetrated by them usuay invoves a poicy hoder or a distributor. 29
(a) Misconduct - Infated bi for genuine treatment by adding costier medicine or increasing ength of stay. Action 1 - Warning with temporary suspension for 6 months from industry business Action 2 - Pan-industry suspension (b) Misconduct - Fake and fabricated caim document on commission basis provided to customer. Action 1 - Permanent dis-empanement Action 2 - Pan-fraudindustry backisting Action 3 - Add to name and shame ist Action 4 - Lega remedy, such as FIR on provider (c) Misconduct - Being part of fraud ring Action 1 - Permanent dis-empanement Action 2 - Pan-industry backisting Action 3 - Add to name and shame ist Action 4 - Lega remedy, such as FIR on provider 4. Agent - are a unique ink between customer and insurer and hence can defraud both customer and insurer. (a) Misconduct - Provide fake poicy to the customer and siphoning off the premium amount. Action 1 - License canceation Action 2 - Across industry backisting Action 3 - Add to name and shame ist Action 4 - Lega remedy, such as FIR on agent (b) Misconduct - Guiding customer to hide PED for getting poicy issued. Action 1 - warning with temporary suspension for 6 months from industry business 30
Action 2 - Pan-industry suspension Action 3 - Add to name and shame ist (c) Misconduct - Being part of fraud ring can faciitate poicies on fictitious name and address. Action 1 - License canceation Action 2 - Pan-industry backisting Action 3 - Add to name and shame ist Action 4 - Lega remedy, such as FIR on agent (d) Misconduct - Faciitate customers to rouge providers for faciitating fraud caims on share basis. Action 1 - License canceation Action 2 - Pan-industry backisting Action 3 - Add to name and shame ist Action 4 - Lega remedy, such as FIR on agent 31
ANNEXURE H Medica Counci of India Code of Ethics Code of Ethics Reguations, 2002 (Pubished in Part III, Section 4 of the Gazette of India, dated 6th Apri, 2002) (Incorporating amendments no. MCI-211(2)/2004-(Ethica) Pubished in Part III, Section 4 of the Gazette of India, Extraordinary dated 27th May, 2004) Sr No Scenario Professiona Misconduct Potentia response 1. Refusa to share records 1.3 Maintenance of medica records - 1.3.1 Every physician sha maintain the medica Lega etter; intimate medica records pertaining to his / her indoor patients counci for a period of 3 years from the date of commencement of the treatment in a standard pro-forma aid down by the Medica Counci of India. 1.3.2. If any request is made for medica records either by the patients / authorised attendant or ega authorities invoved, the same may be duy acknowedged and documents sha be issued within the period of 72 hours. 1.3.3 A Registered medica practitioner sha maintain a Register of Medica Certificates giving fu detais of certificates issued. When issuing a medica certificate he / she sha aways enter the identification marks of the patient and keep a copy of the certificate. He / She sha not omit to record the signature and/or thumb mark, address and at east one identification mark of the patient on the medica certificates or report. 1.3.4 Efforts sha be made to computerise medica records for quick retrieva. 2. Treating doctor 1.4 Dispay of registration numbers - Lega etter; registration 1.4.1 Every physician sha dispay the intimate medica number not on registration number accorded to him by the counci any document State Medica Counci / Medica Counci of India in his cinic and in a his prescriptions, certificates, money receipts given to his patients. 32
Sr Scenario Professiona Misconduct Potentia response No 3. Insurer knowing of a 1.7 Exposure of Unethica Conduct: One-to-one tak, if fraud perpetrated by (whiste bowing) - A Physician shoud expose, not opening up one provider, with without fear or favour, incompetent or knowedge of another corrupt, dishonest or unethica conduct on one the part of members of the profession. UNETHICAL ACTS - A physician sha not aid or abet or commit any of the foowing acts which sha be construed as unethica- 4. Seing drugs without 6.3 Running an open shop (Dispensing Lega etter; icense OR drug of Drugs and Appiances by Physicians): intimate medica icensein doctor's A physician shoud not run an open counci name shop for sae of medicine for dispensing prescriptions prescribed by doctors other than himsef or for sae of medica or surgica appiances. It is not unethica for a physician to prescribe or suppy drugs, remedies or appiances as ong as there is no expoitation of the patient. Drugs prescribed by a physician or brought from the market for a patient shoud expicity state the proprietary formuae as we as generic name of the drug. PROFESSIONAL MISCONDUCT - The foowing acts of commission or omission on the part of a physician sha constitute professiona misconduct rendering him/her iabe for discipinary action. 5. Documentary evidence 7.1 Vioation of the Reguations: If he/she Lega etter; of not abiding by code commits any vioation of these Reguations. intimate medica of ethics 7.2 If he/she does not maintain the medica records of his/her indoor patients for a period of three years as per reguation 1.3 and refuses to provide the same within 72 hours when the patient or his/her authorised representative makes a request for it as per the reguation 1.3.2. 7.3 If he/she does not dispay the registration number accorded to him/her by the State Medica Counci or the Medica Counci of India in his cinic, prescriptions and certificates etc. issued by him or vioates the provisions of reguation 1.4.2. 33
Sr Scenario Professiona Misconduct Potentia response No 7. Notifiabe conditions 7.14 The registered medica practitioner sha Lega etter; ike Choera, Pague, not discose the secrets of a patient that have intimate medica Cases of Meningitis & been earnt in the exercise of his / her counci now Tubercuosis not profession exceptintimated to in a court of aw under orders of the authorities Presiding Judge in circumstances where there is a serious and identified risk to a specific person and / or community; and notifiabe diseases In case of communicabe / notifiabe diseases, concerned pubic heath authorities shoud be informed immediatey. 8. Sef-expanatory 7.20 A Physician sha not caim to be Lega etter; speciaist uness he has a specia quaification intimate medica in that branch. counci 34
ANNEXURE I Lega etter sampe WITHOUT PREJUDICE AND CONFIDENTIAL The Medica Superintendent, Name of the Hospita/Nursing Home, Respected Dr. **** **** Sub: Regarding Heath Insurance Caim pertaining to the treatment taken from & given at your ABC Hospita, <ocation>. This is with reference to a heath insurance caim received by us from one of our poicy hoder who has taken treatment from your ABC hospita over a period of time. The detais of the caimant are as under: Detais: (i.e.: name of LA ; poicy number; caim number; date of admission; date of discharge) Information about diagnosis & ine of treatment: (i.e.: case of...year od, M/F, presenting compaints with duration, diagnosed with, treated by) We need to carefuy examine such caim(s) in the ight of the caim documents submitted by the poicy hoder. Having regard to the iness suffered by our poicy hoder vis-à-vis the documents submitted to us, we need some additiona information to assess the caim. The foowing inconsistencies in the documents submitted to us have been found: Information / observations pertaining to cinica treatment: (i.e.: queries regarding ventiator & tracheostomy or regarding ARF or regarding administration of antibiotics or misceaneous queries regarding treatment given or bood investigations or ICU staff and other physicians/ surgeons invoved in treatment etc). Information / observations pertaining to case management: (i.e.: since the patient was in ICU for 49 days, was on ventiator, underwent tracheostomy and reported to be in acute rena faiure; pease share the names/ quaifications/ registered numbers of other doctors/ speciaists of other discipines / intensivists who were invoved in patient's treatment covering critica issues in mutipe cinica discipines. We observe that on most of the occasions, there is ony one person's handwriting whie treatment of this nature generay shows mutipe hand writings from various doctors who were treating the patient). If the admission invoves a FIR: (i.e.: we appreciate your action of informing the poice on admission (MLC H35). But that time we are certain it woud be a NC as there was no way of knowing that it woud be such a ong drawn course of Rx. As you must be aware that, as per Section 320, IPC "Any hurt which endangers ife, or which causes the sufferer to be, during 35
the space of twenty days, in severe bodiy pain or unabe to fow his daiy routine" becomes a grievous hurt. Thus in this case FIR shoud have been odged. Kindy provide the detais thereof). II. Those pertaining to Medica Record Documentation: ICPs and Nursing record or Cash Memo: (i.e.: we request you to kindy carify on a the above issues and provide us the reevant detais and documents so as to enabe us to assess the caim propery. We soicit your earnest cooperation in this regard. Further, there is a possibiity that the matter may ead to some itigation in which case we bank on your support. We, therefore request you to kindy preserve a the origina records and documents as per the MCI Code of professiona Conduct. The reevant code is quoted beow for your ready reference). 1. CODE OF MEDICAL ETHICS 1.3 Maintenance of medica records: 1.3.2. If any request is made for medica records either by the patients / authorised attendant or ega authorities invoved, the same may be duy acknowedged and documents sha be issued within the period of 72 hours. 1.3.3 A Registered medica practitioner sha maintain a Register of Medica Certificates giving fu detais of certificates issued. When issuing a medica certificate he / she sha aways enter the identification marks of the patient and keep a copy of the certificate. He / She sha not omit to record the signature and/or thumb mark, address and at east one identification mark of the patient on the medica certificates or report. The medica certificate sha be prepared as in Appendix 2. Your information wi prove instrumenta in heping us in the rationa caim adjudication of the above cases. Kindy do the needfu and if you need any carifications, pease do get in touch with us. 36
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