Simplification of Referral System under CGHS

GOVERNMENT OF INDIA
MINISTRY OF HEALTH AND FAMILY WELFARE
LOK SABHA

STARRED QUESTION NO: 284

ANSWERED ON: 13.03.2020

Simplification of Referral Procedure under CGHS

Sukanta Majumdar, Sangeeta Kumari Singh Deo Will the Minister of HEALTH AND FAMILY WELFARE be pleased to state:-

(a) whether CGHS beneficiaries referred by the dispensaries to the empanelled hospitals are forced to seek repeated endorsements for treatment and tests causing great inconvenience and delay in treatment;

(b) if so, the reasons therefor and the response of the Government thereto;

(c) whether there is any proposal to simplify this procedure and allow treatment and all necessary tests on a single endorsement/reference by the dispensary for all senior citizens;

(d) if so, the time by which such a decision is likely to be implemented and if not, the reasons therefor;

(e) whether the Government has invited suggestions from stakeholders regarding revamping of CGHS; and

(f) if so, the details thereof and the action taken thereon?

ANSWER
THE MINISTER OF HEALTH AND FAMILY WELFARE
(DR. HARSH VARDHAN)

(a) to (f): A statement is laid on the Table of the House

STATEMENT REFERRED TO IN REPLY TO LOK SABHA
STARRED QUESTION NO. 284 FOR 13TH MARCH, 2020

(a) & (b) Central Government Health Scheme (CGHS) is a contributory health scheme of Central Government Employees and Pensioners under which subscribers are provided primary healthcare in the form of OPD treatment and medicines from CGHS Wellness Centres. CGHS Wellness Centres act as the nodal point for referral purposes. After consultation with specialist doctor at Empanelled Hospital, the subscriber reports back to the concerned Wellness Centre for issue of prescribed medicines. Also, in cases where the specialist has prescribed diagnostic tests, the MO/CMO at CGHS Wellness Centre endorses listed investigation/ listed treatment procedure. For unlisted investigations/ unlisted treatment procedures, CMO In-charge submits the prescription to competent authority for consideration in case of pensioners. Serving employees do not have to come back to the Wellness Centre and seek permission for unlisted investigations/ unlisted treatment procedures from their Department as per prevailing guidelines. It is part of checks and balances in the system.

In case of Post-operative follow-up cases only one-time referral/permission is required without extension of permission from time to time and treatment / investigations may be undertaken without any endorsement in respect of critically ill CGHS beneficiaries.

(c) & (d) Simplification/ rationalisation of procedures is an ongoing process. With a view to facilitate ease of availing consultations from Specialists at empanelled hospitals, Government has permitted elderly CGHS beneficiaries aged 75 years and above to seek consultations from Specialists without any referral and undergo treatment/ investigation without endorsement. Permission is required only for unlisted treatment procedure/ tests in non-emergency conditions.

(e) & (f) Yes, Sir. Government has invited suggestions from CGHS beneficiaries and other stakeholders regarding revamping of CGHS. The suggestions/ feedback received have been examined by a duly constituted Committee. The Committee has submitted its report for consideration.

TREATMENT IN CASE OF EMERGENCIES

CGHS beneficiaries have the option to go to a nearby Government Hospital / Empanelled Private Hospital or even any Private Hospital, in case of emergency.
However, if treatment is undertaken at private non- empanelled hospitals under emergency, reimbursement will be limited to CGHS rates or actual, whichever may be lower. Since, non-empanelled private hospitals often charge at rates different from the CGHS rates there will be difference in the amount reimbursed if the private hospital charges are higher than CGHS rates.
Procedure for Emergency Admissions

CGHS beneficiaries can take treatment in an emergency as follows:

Any nearest Government Hospital of their choice, for the required emergency, like Sri Jayadeva Institute of Cardiology for cardiac problems.

In any CGHS Empanelled Private Hospital on production of valid CGHS plastic/ self-printed/ paper(index) card. The CGHS Empanelled Hospital are bound by MOA with CGHS to provide cashless facility/ credit facility to CGHS beneficiaries in an emergency situation. Failure to provide such cashless/ credit facility to CGHS beneficiaries in an emergency situation shall invite penal action by CGHS as per MOA. The CGHS Empanelled Hospitals under no circumstances shall refuse to admit CGHS beneficiaries in an emergency. The CGHS Empanelled Hospitals under no circumstances shall insist for referral from CGHS units. CGHS Empanelled Hospitals will verify only the validity of the CGHS plastic/ self-printed/ paper(index)card and shall not harass the CGHS beneficiary(even if the beneficiary is from outside CGHS city/other CGHS city).

Individual beneficiaries may decide to use their own health insurance cards for the hospitalisation. In such cases they are eligible for “dual claim” as per rules where the first claim is made to the insurance company. A set of certified documents submitted/ issued by the insurer may then be submitted to the CGHS for reimbursement as per rules. The limitation being the CGHS rates in force, and in any case, shall not exceed the total expenditure incurred.
In case the individual cannot approach/ or is not in a position to reach an Empanelled Private Hospital for admission, he may be admitted in an “emergency” at any hospital of his choice or as is dictated by circumstances of the emergency.
The bills may be submitted to the concerned Department/ Wellness Centre with the detailed bills including breakup for room, laboratory, investigations, pharmacy etc. in duplicate. The same has to be accompanied by a covering letter explaining the nature of “emergency” circumstances. Please refer the MRC section of this website for further details. The new forms have to be downloaded, duly filled up and submitted.

CGHS Empanelled Hospitals should not refuse Admission for Emergency Cases

In emergency the CGHS empanelled hospitals will not refuse admission or demand an advance payment from the CGHS beneficiary.

CGHS vide its OM No. S.11011/29/2019-EHS dated the 13th September 2019 , has reiterated that in emergency the empanelled hospitals will not refuse admission or demand an advance payment from the CGHS beneficiary or his family member and will provide credit facilities to the patient.

In accordance with the Memorandum of Agreement between the CGHS empanelled Hospital and the Government of India, refusal to provide treatment to bonafide CGHS beneficiaries in emergency cases and other eligible categories of beneficiaries on credit basis, without valid ground, would attract disqualification for continuation of empanelment.

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