West Bengal Health Scheme beneficiaries often face a lot of problems e.g. Improper Medical facilities from empanelled hospitals / nursing homes, difficulties while reimbursement of medical bill for final settlement and co-operation from the Health Care Organizations as well in this regard. Previously Govt. of West Bengal issued a Guidelines to H.C.O’s vide Finance Department Notification No. 796-F (MED), dated 31.01.11. Govt. issued following further Guidelines for empanelled Health Care Organizations for Medical Treatment under the West Bengal Health Scheme, 2008 which may be appended with the previous one.
- Prior permission from the West Bengal Health Scheme Authority is required whenever treatment costs exceed Rs. 2,50,000/-.
- All drugs prescribed should be in generic names as far as possible. If generic names are not used, the justification for use of branded drugs should be provided. Quality of drugs will not be acceptable as justification for the use of branded drugs. The pharmacy should endeavor to procure and supply the cheapest available generic form of the prescribed drug, keeping in view the quality of the drug procured.
- The use of Antibiotics should always be as per the antibiotic policy of the Hospital and based on culture report. ‘Shot gun therapy’ should be strictly avoided. Whenever antibiotics costing more than Rs. 1000/- (One thousand) per dose are used, the Chief of the Hospital infection Control Committee (HICC) should be consulted and together the Consultant in charge of the case and the chief of the
HICC should certify that the most cost effective evidence based antimicrobial treatment has been prescribed. The chief of the HICC should be consulted whenever a change in the antibiotic regimen is contemplated in such patients.
4. Whenever the total cost of pharmaceuticals exceed Rs. 10000/- (Rs. Ten Thousand) daily, the Director Medical Services or equivalent shall be consulted and he, along with the Consultant in charge of the case, should certify that evidence based cost effective treatment has been prescribed in the case.
5. In case of cancer chemotherapy whenever the cost of therapy per cycle exceeds Rs. 5000/- (Five Thousand), the prognosis of the patient is to be clearly mentioned along with the justification for the use of the chemotherapy drugs with regard to the expected survival/palliation of the patient.
6. The bed rent shall include the cost of all special mattresses and other such equipments/ devices/ nebulization.
7. The cost of investigations will be inclusive of cost drawing the samples. This also applies to estimation of blood glucose using glucometer.
8. Consultation fees in the ICU/High Definition Unit will be provided for the treating Specialists/ Super Specialists only (Names of doctors with qualification are to be mentioned in the Bill).
9. The use of disposables/consumables should be kept to the levels. The maximum allowable in all cases shall be (non package treatment):a. Gloves -10 pairs (all types included) per day
b. Masks- 2 per day
c. I. V. sets – 3 per week
d. venflon or substitute 3 per week
e. B. T. set -3 per week
f. Urinary catheters (all types included) – 3 per week
g. Urobag – 3 per week
h. Suction catheter -1 per day
i. Syringes -10 per day (all capacities included)
10. For non adherence to the above guidelines, the additional costs will have to be deducted from the final bills of the HCO.
11. In case of any discrepancy/difficulty, the West Bengal Health Scheme Authority is to be contacted prior to preparation of the final bill.
- The main procedure done is to be shown as the initial package.
- Sub procedures requiring substantial additional consumables, skill or operative time is to be shown as subsequent packages.
- Not more than two packages should normally be performed or planned. Permission of the West Bengal Health Scheme Authority is necessary for more than three packages.
- For minimally invasive cases becoming open cases, cost of minimally invasive surgery package will not be allowed for billing.
- In case of dual chamber pacemaker implantation, the medical reason for the non suitability of single chamber pace maker is to be justified, not just that it is more physiologically suited. In case of implantation of drug eluting stent, multiple stenting, opinion of Cardiac Surgeon will be required whether Bye-pass Surgery or PTCA with stenting is medically suitable for the patient. If digital hearing aid is prescribed, the specific reason for conventional hearing aid not being medically suitable is to be mentioned. Permissions of the West Bengal Health Scheme Authority are to be taken in all the cases by the H.C.O.s in advance.
- Code Nos. of procedures and investigations must be mentioned in the Bill.
- Name and qualification with Registration No. of the Specialists/ Super Specialists must be mentioned in the Essentiality Certificate.