Abstract of Dissertation

Keyword : Unspecified package requests; Rashtriya Swasthya Bima Yojana; RSBY empaneled hospitals

Objective : The objective of the study was to design specific packages for unspecified package requests, to identify district wise trends and to include the identified package in the package list. The study was done keeping in mind the packages which are not defined by RSBY Which are called unspecified packages.

Background : Rashtriya Swasthya Bima Yojana, a central government scheme, provides package rates for various ailments and treatment procedures. The packages which are not defined are called unspecified packages. To verify the unspecified packages the insurance company requires Unique Reference Number, the available sum insured and adjudication of the request i.e., approval, rejection, and query. The insurance company verifies the requested package and amount by the hospital if required Insurance Company provides the different package amount and code is submitted to the hospital. The Insurance company rejects the request on the basis of sum Insured exhausted and Non-requirement of the treatment. The Insurance Company shall raise the query with the hospital in case of any discrepancy. For unspecified cases authorization code is generated.

Methodology : The study was conducted at Reliance General Insurance, Hyderabad for three months duration. The study included beneficiaries of RSBY impaneled hospitals. Sample Size of 400 beneficiaries was taken. It was a cross-sectional Analytical study.

Findings : The result indicates that the primary reason for cases being categorized as unspecified cases is unavailability of those packages. These packages are Atrial Septal Defect Closure, Arteriovenous Fistula Creation, Renal Transplantation Trans-Obturator Tape operation, Trendelenburg operation, etc. As per district wise trends, District 1 and District 2 has got the maximum number of unspecified claims from government organizations whereas districts like District 3 and District 4 has got the maximum number of unspecified claims from a private organization.

Recommendations : On the basis of the results obtained designing of packages for the unspecified cases, recommendations for pricing has been done as per Central Government Health Scheme standards.