Guidelines For Payment In Special Cases During Hospital Admission

The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) has established clear guidelines for handling payments in special cases during hospital admissions. It ensures that the hospitals and payers are clear on the payment process when a patient’s treatment deviates from the normal course.

However, there are situations where deviations occur, such as patients leaving against medical advice, deaths during treatment, or referrals to other hospitals. These guidelines address how payments should be handled in such special cases.

Basic Principles During Payment Process

Understanding the basic principles is crucial for both hospitals and payers to navigate the payment process in special cases.

• Timely Reporting: Hospitals must report deviations within 24 hours (72 hours for public hospitals) to the State Health Agency (SHA) or Insurance Company (Insurer).
• Audit Requirement: Payments will be made only after a successful audit by the SHA or Insurer, to be completed within 15 days of receiving the information.
• Deviation Limit: These deviations should not exceed 5% of the cases in any particular hospital.

Payment For Special Cases

Different scenarios require specific payment protocols that provide detailed instructions for each special case to ensure fair and consistent payments. Below, we have discussed some of the major special cases:

1. Leave Against Medical Advice (LAMA) / Discharge Against Medical Advice (DAMA)

Patients sometimes choose to leave the hospital against the advice of their physicians. Payments in such scenarios are handled as follows:

Surgical Cases:

• Before Surgery: Payment is made based on the daily package rate for the full number of days the patient was admitted.
• After Surgery: Hospitals receive 75% of the package rate, provided they submit daily case sheets and operating theatre (OT) notes for auditing.

Medical Cases: Payment is made for 100% of the daily package rate for the full number of days the patient was admitted.

2. Patient Dies in the Hospital

If a patient dies during their hospital stay, payments are processed as follows:

Surgical Cases:

• Before Surgery: Payment based on the daily package rate for the full admission period.
• During Surgery: 75% of the package rate if the patient dies on the operating table.
• After Surgery: Full package rate, subject to a detailed medical audit.

Medical Cases: Payment for 100% of the daily package rate for the full admission period.

3. Patient Referred to Another Hospital

Patients may need to be referred to other hospitals for further treatment. Referrals should ideally be to other empanelled hospitals. Payments are processed as follows:

Referred to an Empanelled Hospital:

• Before Surgery: Payment based on the daily package rate for the referring hospital, with the receiving hospital eligible for the full package rate.
• After Pre-Anaesthetic Checkup (PAC) but Before Surgery: The referring hospital gets 15% of the package rate, and the receiving hospital gets 85%.
• After Surgery: The referring hospital receives 75% of the package rate, and the receiving hospital gets the full rate for any new surgical package or daily rate for medical packages.

Referred to a Non-Empanelled Hospital: No payment will be made if a referral is to a non-empanelled hospital, except in exceptional circumstances.

Conclusion

These guidelines ensure clarity and fairness in the payment process for special cases during hospital admissions under PM-JAY. Hospitals must adhere to reporting timelines and documentation requirements to qualify for payments. 

It also helps in minimizing disputes and ensuring that patients receive necessary care without financial hurdles. Compliance with these guidelines is essential for the smooth functioning of the PM-JAY scheme, for complete guidelines, to know more, you can download the official PDF from here.

What Should Hospitals Do If A Patient Leaves Against Medical Advice?

Hospitals must report the deviation within 24 hours and submit the required documentation for auditing to receive payment based on the daily package rate for the admitted period.

How Are Payments Handled If A Patient Dies During Treatment?

Payments depend on the timing of the death relative to surgery. Before surgery, the daily package rate is paid; during surgery, 75% of the package rate; and after surgery, the full package rate, all subject to audit.

Can Hospitals Refer Patients To Non-Empanelled Hospitals?

Referrals should ideally be to other empanelled hospitals. Payments are not made for referrals to non-empanelled hospitals, except in exceptional cases with strong justification.

What Is The Audit Process For These Special Cases?

SHA or Insurers conduct audits within 15 days of receiving deviation reports from hospitals. Payments are made only after successful audits.

How Are Payments Calculated For Referred Patients?

Payments vary based on the referral timing. Before PAC and surgery, the daily rate is paid; after PAC but before surgery, 15% and 85% splits; and after surgery, 75% and full package rate splits between referring and receiving hospitals.