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In order to improve information flow to the policyholders about the hospitals engaged by insurers and TPAs for providing cashless health services, it is proposed to mandate insurance companies and TPAs to disclose various parameters about the network hospitals, in their respective websites. With this objective, a draft Circular on " Disclosure of Hospital Quality Indicators" is proposed to be issued. All stakeholders are requested to forward their comments/suggestions on the same, by 14th February,2020 in the attached format. The comments may be mailed to aparnakavuri@irdai.gov.in
(Suresh Mathur)
Executive Director
Draft Circular on disclosure of Hospital Quality Indicators
To
All Insurers and TPAs,
Re: Standards for hospitals in the provider network – Disclosure of Quality Parameters
1. Reference is invited to the provisions of Regulation 29 (iv) of IRDAI (Health Insurance) Regulations, 2016 wherein Insurers are directed that they shall keep the insured informed of the list of Network Providers and display the same on their website. Such list shall be also displayed geography wise and updated as and when there is any change in the Network providers.
2. Reference is also invited to the provisions of Clause (dd) of Schedule I read with Regulation 23 of IRDAI (TPA-Health Services) Regulations, 2016 wherein it is specified that TPAs shall disclose the list of network hospitals with whom it has valid agreement to policy holders, prospects and general public.
3. With respect to the Network Providers engaged for rendering cashless services, Insurers and TPAs, wherever applicable, shall also disclose the following details of the network providers and these details shall be updated as at 31st March of every financial year and be disclosed.
TABLE - A
| S No. | Particulars |
| 1 | Total Bed strength of the Hospital |
| 2 | Number of Doctors (as at 31st March, yyyy)(2a+2b+2c) |
| 2a. | Total number of Full time doctors with qualification approved by MCI in the rolls of the Hospital? |
| 2b. | Number of consultants)(who are not on rolls of the hospital) |
| 2c. | Number of surgeons or interventionists (Like cardiologists, Gastroenterologist- not on full time roll of hospital) |
| 3 | Total number of qualified nurses (B.Sc. Nursing, GNM,) in the hospital |
| 5 | Total number of intensive care unit beds in the hospital |
| 6 | Number of doctors exclusively available for ICU |
| 7 | Total number of Post graduate (MD (anaesthesia, Gen Med, etc.)) qualified doctors exclusively available for ICU. |
| 8 | Number of doctors with the qualification of MBBS, available for ICU exclusively taking all the shifts together |
| 9 | Number of qualified nurses available exclusively in the Intensive care Units taking all the shifts together |
4. Insurers and TPAs shall also disclose the following quality parameters relating to the network providers.
TABLE - B
| | Parameter | Calculation |
| 1 | DOCTOR- BED RATIO | Number of Medical Practitioners with MBBS Qualifications as proportion of beds |
| 2 | NURSE-BED | Number of Qualified and Registered Nurses (GNM, Post BSc, BSC. & M.SC. (Nursing) as proportion of occupied beds. |
| 3 | DOCTOR-PATIENT(BED) RATIO IN ICU | Number of Medical Practitioners exclusively for ICU, as proportion of beds in ICU |
| 4 | NURSE-PATIENT(BED) RATIO IN ICU | Number of Qualified Nurses exclusively for ICU, as proportion of Beds in ICU. |
| 5 | AVERAGE | As per the calculation of respective TPA and Insurer taking into account all the admitted cases |
| 6 | AVERAGE DISCHARGE TIME | As per the calculation of respective TPA and Insurer taking into account all the admitted cases |
| 7 | AVERAGE LENGTH OF STAY (ALOS) FOR MEDICAL CASES | Numerator: Total medical inpatient days (during the last financial year) relating to TPA/insurer (As per the calculation of respective TPA and Insurer taking into account all the admitted cases.) |
| 8 | AVERAGE LENGTH OF STAY (ALOS) | Numerator: Total Surgical cases inpatient days (during the last financial year) relating to TPA/insurer Denominator: Total no. of discharges of surgical cases relating to TPA/insurer (As per the calculation of respective TPA and Insurer taking into account all the admitted cases.) |
| 9 | C_SECTION RATE | Numerator: Total number of Caesarean sections performed during the last financial year) relating to TPA/insurer (As per the calculation of respective TPA and Insurer taking into account all the admitted cases.) |
5. The policyholders desirous of knowing the above details shall be able to access all the above information on visiting the website of respective Insurer or the TPA.
6. The above directions shall come into effect from xx/xx/xxxx.
7. The above instructions are issued under the powers vested with Regulation 31 (e) of IRDAI (Health Insurance) Regulations, 2016.
General Manager (Health)
