Empaneled Healthcare Providers (EHCPs) have expressed concerns over delays in claims payments and unfair rejection of claims by FGI under the CMHIS and PM-JAY. NHPS said it will to push FGI to release payments by February 19, ensuring that hospitals receive their dues.
By Imna Longchar, TFM Nagaland Correspondent
Empaneled Healthcare Providers (EHCPs) have expressed concerns over delays in claims payments and unfair rejection of claims by FGI under the Nagaland Government’s Chief Minister Health Insurance Scheme (CMHIS) and the central government’s Pradhan Mantri Jan Arogya Yojana (PM-JAY). Many hospitals are facing financial strain due to these delays, which are impacting their ability to operate smoothly and pay staff salaries on time.
Pressing concerns of EHCPs came to the fore during a physical cum VC meeting chaired by the Commissioner & Secretary to the Government of Nagaland and the CEO of Nagaland Health Protection Society (NHPS) on February 13.
In the meeting, CEO Thavaseelan K (IAS), who is responsible for the day-to-day operations of the NHPS, informed that FGI (Future Generali Insurance India Limited) has resumed making payments for claims where no misuse has been identified. However, it was noted that the amount released so far is not sufficient considering the number of claims due to hospitals.
This year, the number of claims has significantly increased, with 18,000 claims totalling Rs 80 crores, compared to 11,000 claims worth Rs 50 crores last year under CMHIS.
He urged EHCPs (Empaneled Healthcare Providers) not to discontinue services under the PM-JAY and CMHIS schemes, as this would significantly impact beneficiaries who rely on them for healthcare access.
He also reaffirmed NHPS’s commitment to supporting EHCPs in Nagaland and requested continued cooperation from all stakeholders to ensure the sustainability of the schemes. Despite Rs 88 crore already being processed, there is still an outstanding amount of Rs 35 crores that has yet to be paid.
Key Issues and Resolutions
- Delayed Payments: Despite ₹88 crore being processed, ₹35 crore remains unpaid. NHPS is working closely with FGI to expedite payments, with a commitment to release ₹8 crore by February 19, 2025. The EHCPs requested a clear timeline for payment releases to resolve financial challenges.
- Unfair Claim Rejections: EHCPs raised concerns about unfair rejections by FGI, often due to poor documentation. NHPS emphasized the need for standard documentation criteria and flexibility in evaluating rejected claims. The State Medical Committee (SMC) is reviewing all flagged cases, and hospitals will be given the opportunity to present their cases.
- Fraud Investigations: NHPS assured transparent and fair investigations, with invalid rejections to be revoked. EHCPs requested referral of proven fraud cases to the Nagaland Medical Council for further action as per NMC Rules and Regulations.
- Contractual Obligations: FGI is responsible for approving and paying claims until March 31, 2025, when the contract officially expires. NHPS clarified that FGI will honor all pre-authorization approved claims until the contract’s expiration.
- Payment Reconciliation: A major issue identified was that some hospitals have not yet received payments that FGI claims to have processed. FGI representatives have been visiting hospitals for payment reconciliation, and hospitals were urged to reach out to NHPS if they continue facing payment discrepancies.
EHCPs agreed to continue providing services under PM-JAY and CMHIS to prevent disruption to beneficiaries. NHPS said it will push FGI to release payments by February 19, ensuring that hospitals receive their dues.
The government has assured consideration of long-term improvements to the scheme, ensuring better compliance, documentation, and claim processing. The meeting concluded with a shared commitment to resolving payment issues, maintaining ethical medical practices, and ensuring that the scheme remains viable for the people of Nagaland.