Nagaland: NHPS flags hospital over NUCU billing row; Rs 5.15 lakh charge sparks CHIS concerns

Kohima, July 9: The Nagaland Health Protection Society (NHPC) has taken up the issue with the concerned department after a beneficiary admitted at Neonatal Intensive Care Unit(NICU) under Chief Minister Health Insurance Scheme (Employee and Pensioner) [CMHIS (EP)] alleged being charged Rs 5,15,704 by an empanelled hospital.

According to the complaint, only Rs 1,63,975 was processed and settled as the eligible claim amount under the scheme, leaving a substantial amount in dispute.

In an official statement issued by Thavasecian K. IAS. CEO of NHPS, the Society said it has taken up the matter with the concerned hospital and directed it to process the claim strictly as per CMHIS (EP) guidelines.

The Society stressed that all package provisions and claim settlement mechanisms must be fully explored before declaring any treatment component an non-payable.

Reiterating scheme norms, NHPS stated that NICU bed charges are included in approved package rater, along with coverage for paediatric care for newborns. It added that separate add-on packages are available for oxygen support, laboratory services and
diagnostic investigations.

The Society clarified medicines, are reimbursable under the Open Billing system, either as per the ceiling rates fixed by the National Pharmaceutical Pricing Authority (NPPA) or at actual cost.

Consultation fees are part of the package rates and cannot be charged separately, except in cases of approved cross-consultations as per scheme provisions.

On cashless treatment, NHPS reiterated that no additional charges can be levied on beneficiaries except for non-payable items such as diapers and toiletries under IRDAI norms, or where patients voluntarily opt for higher room categories or premium
implants.

In all other cases, treatment must be provided on a cashless basis and recovery of any outstanding amount from the beneficiary is not permissible.

The NHPS has underscored the importance of thoroughly examining and making proper use of all package-related provisions, claim settlement mechanisms, and approval procedures provided under the CMHIS Scheme.

It stated that these avenues must be completely utilised before determining that any particular expense falls outside the scope of the Scheme’s coverage.

The Society also reminded the empanelled hospital of their obligations under the Memorandum of Understanding (MoU) signed with the State Health Authority, which binds them to provide cashless treatment to all eligible AB PM-JAY and CMHIS beneficiaries at approved package rates by virtue of the agreement.

The NHPS has advised the hospital to refrain from recovering any unauthorised amount and urged both beneficiaries and healtheare providers to report issues promptly. Assistance can be sought through the toll-free helpline 1800-202-3380 via call or WhatsApp.

Even as the NHPS reiterated the rules, government employees ind pensioners under CMHIS (EP) have raised concerns over gapsin implementation.

A government servant linked to the case, speaking anonymously, sid delays in settlement of claims are forcing hospitals to either deny CMHIS cards or demand advance payments.

“Hospitals are waiting months for reimbursement. In such cases they refuse cashless treatment or ask patients to pay upfront.” a sources said.

Hospital sources pointed to multiple systemic issues, including pending dues to empanelled hospitals, lack of clarity on coverage and package rates, and reluctance among hospital to undertake high-cost procedures such an NICU, ICU and major surgeries under the scheme:Concerns were also raised over grievance redressal, with beneficiaries claiming delayed responses and limited accountability when hospitals deny treatment. Many alleged that delays in government payments are effectively shifting the financial burden onto patients.

“The scheme is supposed to be cashless, but in reality, people are asked to pay first and claim later. For most employees and pensioners, arranging such large sums is not feasible.” the source added.

The episode has once again highlighted the widening gap between policy assurances and ground-level execution of CHIS (P) with beneficiaries caught between unpaid hospital dues and delayed reimbursements.

Also read: Eggs, fish and chicken on a handcart: Akhil Gogoi’s protest targets ‘syndicate raj’ in Assam

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