Each accredited hospital signs an agreement to:
• Provide a help desk staffed 24 hours to receive and assist Yeshasvini members
• Admit all patients free of charge for OPD, the covered services of surgeries, at general ward admission
• Bill the Trust only at the tariff for special admission
• Submit all claims to FHPL within 10 days of discharge with appropriate documents
First Admission Report (FAR) is sent to FHPL for pre-authorization, response is often within 3 days. For surgeries exceeding Rs. 30,000 on the tariff scale, FHPL will do an independent investigation to ascertain the necessity of the operation.
There were 114 hospitals in the provider network in the first year and 136 in the second year. One hospital left and 23 were added for the second year. FHPL’s objective is to maintain a limited number of hospitals, thereby enabling higher number of patients per facility and giving the Trust negotiating power. A reasonable geographic distribution is required so that most beneficiaries do not have to travel more than 50 kilometers to benefit from the plan.
The Karnataka State Co-operative Department has had the responsibility to communicate the plan and enrol members, and has done so at no cost to the Trust. Each district office of the Co-operative Department is responsible to contact their co-operative societies to enrol members. All receipt books are retrieved by the start of the plan year and premium submitted by the co-operative to the co-operative bank is reconciled. The ID cards are distributed via the co-operative society.
During the enrolment period a publicity campaign is conducted by the Department of Co-operative including TV ads and pamphlets describing the plan.
For the first two years participants paid Rs. 60/year for each person insured. In Year 1 the government of Karnataka provided a corpus of Rs. 45 million. Up to the date of the report, there has been no corpus transferred to the Yeshasvini Trust for Year 2. For Year 3 the premium rate has been set at Rs. 120 per person.
The TPA, FHPL, has the task of maintaining the data base, accrediting hospitals, training hospital staff on the Yeshasvini plan, auditing service agreements with network hospitals, approving treatment of beneficiaries, monitoring claims to prevent over-utilisation, process reimbursement to network hospitals and collect feedback from members.
Hospital accreditation follows an outlined procedure and is managed to ensure geographic distribution, quality facilities and managed number of facilities.
FHPL has 14 district coordinators for the Yeshasvini plan covering the 26 districts in the state of Karnataka. The district coordinators work with the network hospitals to train staff on the Yeshasvini plan, check on high value surgeries (with the assistance of medical staff), meet patients during treatment, check quality and report provider misbehaviour.
FHPL has a team of physicians that review retrospectively the network hospitals case management. This monitoring of claims noted that the number of hysterectomies performed on young women was higher than expected: a circular was sent to hospitals stating appropriate age range to perform such operations. It was also noted that the number of Caesarean sections required corrective action by network hospitals.
One a month the Trust meets to approve claims screened by FHPL. For a network hospital reimbursement comes between 15-45 days following discharge.
FHPL has been the TPA for the first two years of the Plan and has had its contract renewed for the next two years.
