In a major relief for central government employees, the Ministry of Health and Family Welfare has issued new guidelines to curb fraudulent billing and overcharging by healthcare organisations (HCOs) empanelled under the Central Government Health Scheme (CGHS). The move to launch a crackdown against such hospitals to protect beneficiaries from malpractice and ensure compliance with CGHS protocols.
New CGHS guidelines to address complaints
The Directorate of CGHS has received complaints from beneficiaries regarding overcharging, denial of treatment, and fraudulent billing practices by empanelled hospitals. To tackle these issues, detailed guidelines have been introduced for strict adherence:
The new guidelines state that hospitals must not deny services to any eligible CGHS beneficiaries. “Beneficiaries/ In cases of patient death or when the patient is in a coma, the signatures of the beneficiaries’ attendants, along with their mobile numbers, must be obtained on the final bills for all Indoor and OPD services, including daycare, laboratory services, dialysis, etc.”
Reporting requirements
HCOs must report specific cases, such as non-referral cases, emergency admissions, and direct visits of beneficiaries aged 70 and above, within 24 hours to the respective Additional Director via email; and failure to report cases will result in non-approval of claims, the ministry says.
Transparency in bed availability
Hospitals must prominently display the availability of beds in various wards and ICUs for the benefit of visiting patients; and beneficiaries must be allocated their entitled ward category. Assigning a lower category is prohibited, it says.
According to the latest guidelines, prescriptions must use generic names in capital letters. Specific brand insistence by HCOs is not allowed; and hospitals must accept medicines supplied by CGHS and ensure proper cold chain maintenance.
If hospitals refuse to accept CGHS-restricted medicines, they must provide the purchase invoice for reimbursement, the guidelines clarify.
For implants exceeding CGHS ceiling rates, beneficiaries’ informed consent is mandatory, acknowledging the additional cost. This consent must be attached to the bill. Hospitals must prominently display information about CGHS services, guidelines, and packages, the new guidelines state.
Updating nodal officer details
Changes in the Nodal Officer’s details must be communicated immediately to the respective additional director; and only beneficiaries’ phone numbers should be entered into the BIS/TMS portal.
Geo-tagged photos of admitted cases must be uploaded daily to the TMS portal. OPD cases must have same-day photo uploads. All HCOs are required to set up a CGHS Help Desk or Kiosk on their premises to assist beneficiaries.
Hospitals are strictly prohibited from collecting or retaining hard copies of CGHS cards.
Adherence to package rates
Hospitals must not charge beneficiaries beyond the package rates prescribed by CGHS, the guidelines say.
Fraudulent billing and penalties
Submission of fake bills or forged documents will be treated as financial fraud. Legal actions, including FIRs and de-empanelment, will be initiated against violators.
Failure to comply with these guidelines will attract serious consequences, including blacklisting or termination of the Memorandum of Agreement (MOA). The Ministry has urged all empanelled HCOs to ensure strict compliance with the new directives to safeguard the interests of CGHS beneficiaries.