SHA resolves AB-PMJAY thrombolysis package issues at SMHS

Insurance Company to accept less than 24-hrs stay cases

Irfan Tramboo

SRINAGAR, Jan 30: In a major relief to the patients requiring thrombolysis at SMHS Hospital, the State Health Agency (SHA), J&K has finally resolved the issues which were leading to the non-coverage of such patients under the AB-PMJAY.
Taking note of the issue, the SHA has issued a number of directives in this regard, through which the operational issues, faced earlier, will be now resolved.
Under the directives now, the patients received at SMHS Hospital, who require thrombolysis, Systemic Thrombolysis package with the package code MCO20A under Health Benefit Package (HE3P) 2.2 issued by NHA may be blocked by the hospital.
Such patents received at SMHS hospital are initially thrombolysed and subsequently shifted to adjacent Super specialty Hospital for further treatment.
“If a doctor at SMHS hospital, Srinagar determines that patient doesn’t need thrombolysis, such package cannot be booked for such patients,” SHA said.
SHA stated that post thrombolysis, if concerned doctor decide not to shift patient to Super Specialty Hospital, “then same will be covered under the scheme if the length of stay is more than 24 hours at SMHS Hospital.”
It is to be noted here that there was an issue of shifting of such patients to the Super Speciality Hospital as well as shorter stays at the SMHS, leading to problems, and ultimately affecting the patients. The cases with the shorter stays were not accepted by the insurance company, leading to rejection of claims.
There were also instances where the patients were not provided the benefits under the scheme by the hospital. The guidelines now issued, it appears, will address the issue once and for all.
‘Excelsior’ had earlier reported about the matter in December last year, especially, how the patients were facing issues due to the inability of the authorities in resolving the operational issues of the package at one of the major tertiary care hospitals in Srinagar.
In response to the report, the SHA had stated that such patients were being provided with the necessary benefits under the scheme at the hospital, while also touching upon the prerequisites mandatory for booking the package under the scheme. These prerequisites resulted in the operational issues.
Further, the guidelines issued state, post thrombolysis, if the patient is shifted to Super Specialty Hospital before 24 hours from the time of admission of patient, “the patient will be discharged from the Transaction Management System (TMS) and a proper referral will be provided by the competent doctor.”
The Insurance Company, SHA has noted, shall accept such cases of referral even if the length of stay in SMHS hospital is less than 24 hours.
“SMHS Hospital Srinagar shall ensure that patient is discharged in TMS on time, so that Super Specialty can block another suitable package on TMS for the same patient.”
The hospital has been further directed to ensure that proper protocols are followed for referring such patients and an internal mechanism is established to ensure checks and balances in this referral system.
In case a patient is received on an emergency basis at Super Specialty Hospital and requires immediate stenting, SHA said, then it will be at the discretion of the doctor to decide whether mandatory diagnostic tests are required or not.
“Insurance Company shall ensure that such preauthorization/claims are entertained without undue query/delay,” SHA directed.
These directives, SHA said, have been issued after it came to the fore that there are some operational challenges regarding Systemic Thrombolysis package, noting that the procedure is emergency in nature and treatment of such patients must be prioritised to save a precious life.