AFVOA Newletters of Year 2004

Page 49 of 153 the initial period wherein there are unresolved grey areas, leading to members facing situations where they have had to pay for services obtained from empanelled medical establishments. For example, a member had to pay approximately Rs 4000/- up-front to Apollo Hospitals for certain tests that were carried out prior to a prostrate surgery, despite Apollo Hospitals, Chennai being empanelled for treatment of ECHS members, and despite having being referred there in the proper manner. In yet another case, a member referred for cardiac investigations to Harvey Heart Hospitals had to pay up initially, and after these were done, and he took up the case with the O i/c ECHS Polyclinic at Chennai, most of the money paid to Harvey Hospitals was refunded by the hospital to the member, except for the doctor’s fees in respect of the consultant cardiologist who had seen the test results. In both these cases, the members were in a position to pay up-front. 21. Situations will arise whenever members are referred to empanelled medical establishments, wherein they have to undergo tests/procedures not only in-house in the particular facility, but also in specialist centres. Such cases may come about in the form of further referrals for allied or unrelated tests, procedures, or even of treatment etc such as scans, etc, or-even purchase of consumables such as drugs that are not available in-house or blood from authorised blood banks outside the ambit of the centre to which the member is referred to. 22. The implications of the above lacunae are obvious, and the adverse effects will be all the more with members who are less financially secure, or in a more delicate condition of health, or who land up at an empanelled facility that is in the interior areas with no immediate recourse to redressal of the problem. 23. It is suggested that firstly, the MOA with each and every medical facility be so drawn up that a member is protected from having to pay cash at any point of time when he/she is referred in the normal course (and it is not an emergency treatment request). If tests/procedures/consultation outside the ambit of the empanelled facility are called for by reason of such tests, procedures, consultation expertise not being available at that facility(even temporarily),it should not be the case that a member has to pay upfront. The ECHS organisation will have to ensure that it is not subjected to variable, non-fixed charges for such tests/procedures/consultations. Secondly, in the case of consumables like blood/plasma/drugs etc. that may not be available in house within the empanelled facility, the MOA will have to cater for clauses that lay down the quality specifications that are to be adhered to. Response by Gen Girish 24. a) Payment demanded by empanelled hospitals: i) Members are advised not to pay, and to refer such cases to the polyclinic for processing. ii) Issues, such as the one concerning the Patron, have been noted for implementation while empanelling hospitals b) Outsourcing by empanelled facility: Member/ECHS not to pay. Issue already included in the draft MOA. c) Quality/specifications of consumables ECHS empanelling quality hospitals, where norms/specifications are adhered to. Classification of empanelled facilities 25. As of now, the various facilities are being empanelled for various speciality