DIMAPUR — Against
the backdrop of the recent notice put up by Eden Medical Centre, Dimapur, that
the hospital will be suspending all services relating to Ayushman/PMJAY/CMHIS
from Dec. 30, 2024, the Nagaland Health Protection Society (NHPS) has assured
that all claims beyond the “turnaround time” would be cleared before Dec. 31.
In an undated notice, Eden Medical Centre informed that the
hospital will be suspending all services relating to the health insurance
scheme till all the dues owed to the hospital are compensated in full.
When contacted, an official of the NHPS disclosed that a
meeting was held with the insurance company on Saturday wherein it was decided
that all claims beyond the turnaround time would be cleared before Dec. 31 this
year.
According to the official, the turnaround time claim
includes all empanelled hospitals, both within Nagaland and outside the state.
Hospital claims are expected to be paid within 15 days, and
those claims that exceed the 15-day period are treated as beyond the turnaround
time. The insurance company will clear all claims that fall beyond the
turnaround time, the official said.
The official also disclosed that within Nagaland,
approximately INR 21 crore in claims are pending, which includes both claims
within and beyond the turnaround time.
While opining that the delay in payment of claims might have
prompted Eden Medical Centre to suspend its services, he, however, maintained
that efforts are underway to resolve the issue through collaboration between
the insurance company and the hospital.
The department is mediating between the hospital and the
insurance company. At the same time, the insurance company is claiming that it
is incurring expenses beyond the allocated premium due to alleged
overutilisation of the health insurance schemes in Nagaland, he said.
The total premium from the government to the contracted
insurance company amounts to approximately INR 93 to 94 crore per annum;
however, the insurance company has already incurred expenses exceeding INR 100
crore, he added.
“The insurance company has also alleged potential ‘abuse or
misuse’ by the hospital; therefore, the NHPS must ensure that the health
schemes are not being misused by the hospital while also ensuring that the
insurance company adheres to the turnaround time for payments.
“Nonetheless, if the insurance company fails to adhere to
the norms and delays payments, it will be required to pay a penalty to the
hospitals,” the official asserted.
Additionally, he informed that the NHPS has already started
investigating potential abuse by the hospital, and if the hospital is found
guilty, it will also be required to pay a penalty as well.
Further, efforts should be made to streamline the process in
Nagaland, aligning with the standards set by the National Medical Commission
(NMC), he said.
The official encouraged citizens to utilise the toll-free
call centre to enquire about the availability of schemes for treatment both
within Nagaland and outside the state.
