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To
All Insurers and TPAs,
Re: Standards for hospitals in the provider network– Disclosure of Quality Parameters
1. Referenceis invited to the provisions of Regulation 29 (iv) of IRDAI (Health Insurance)Regulations, 2016 wherein Insurers are directed that they shall keep theinsured informed of the list of Network Providers and display the same on theirwebsite. Such list shall be also displayed geography wise and updated as andwhen there is any change in the Network providers.
2. Referenceis also invited to the provisions of Clause (dd) of Schedule I read withRegulation 23 of IRDAI (TPA-Health Services) Regulations, 2016 wherein it isspecified that TPAs shall disclose the list of network hospitals with whom ithas valid agreement to policy holders, prospects and general public.
3. Withrespect to the Network Providers engaged for rendering cashless services,
| S No. | Medical infrastructure of the Hospital |
| 1 | Total Bed strength of the Hospital |
| 2 | Number of Doctors |
| 2a. | Total number of Full time doctors with qualification approved by MCI in the rolls of the Hospital? |
| 2b. | Number of consultants |
| 2c. | Number of surgeons or interventionists |
| 3 | Total number of qualified nurses in the hospital |
| 4 | Total number of intensive care unit beds in the hospital |
| 5 | Number of doctors (with Qualification of MBBS/MD) exclusively available for ICU |
| 6 | Number of qualified nurses available exclusively in the Intensive care Units taking all the shifts together |
| 7. | Accreditation received by the Hospital (Pre-entry level Certificate or higher level of certificate) issued by National Accreditation Board for Hospitals and Healthcare Providers (NABH) or State Level Certificate (or higher level of certificate) under National Quality Assurance Standards (NQAS), issued by National Health Systems Resources Centre (NHSRC)) (Details of Accreditation shall be provided). |
**
|
| Parameter | Calculation |
| 1 | DOCTOR- BED RATIO | Number of doctors as proportion of beds (For the calculation of this ratio “Number of doctors” stated in Sl.No.2 of the Table-A above, shall be used and Beds shall as per Sl no. 1 of Table – A above) |
| 2 | NURSE-BED | Number of Qualified Nurses as proportion of occupied beds. (For the calculation of this ratio “Number of Qualified nurses” stated in Sl.No.3 of the Table-A above, shall be used and Beds shall as per Sl no. 1 of Table – A above) |
| 3 | DOCTOR- BED RATIO IN ICU | Number of doctors exclusively for ICU, as proportion of beds in ICU (For the calculation of this ratio “Number of doctors” stated in Sl.No.5 of the Table-A above, shall be used and Beds shall as per Sl no. 4 of Table – A above) |
| 4 | NURSE- BED RATIO IN ICU | Number of Qualified Nurses exclusively for ICU (Sl No. 6 of Table - A), as proportion of Beds (Sl No. 4 of Table – A) in ICU. |
| 5 | AVERAGE | Time to be reckoned from the time the patient has reported to the hospital till the time of admission of patient. ( As per the calculation of Insurer taking into account all the respective admitted cases in the preceding financial year) |
| 6 | AVERAGE DISCHARGE TIME | Time to be reckoned from the time the patient was advised discharge by the doctor till the time of final discharge of the patient (As per the calculation of Insurer taking into account all the respective admitted cases in the preceding financial year) |
| 7 | AVERAGE LENGTH OF STAY (ALOS) FOR MEDICAL CASES | Numerator: Total medical inpatient days (during the last financial year) relating to insurer (As per the calculation of Insurer taking into account all the respective admitted cases in the preceding financial year .) excluding day care treatment like chemotherapy, radiotherapy dialysis etc |
| 8 | AVERAGE LENGTH OF STAY (ALOS) | Numerator: Total Surgical cases inpatient days (during the last financial year) relating to insurer Denominator: Total no. of discharges of surgical cases relating to insurer (As per the calculation of Insurer taking into account all the respective admitted cases excluding day care treatment like chemotherapy, radiotherapy dialysis etc .) |
| 9 | C_SECTION RATE | Numerator: Total number of Caesarean sections performed during the last financial year) relating to insurer (As per the calculation of Insurer taking into account all the respective admitted cases in the preceding financial year.) |
4. AllTPAs shall provide the link of the insurance company where the said informationis available.
5. TPAsand Insurers shall also disclose the web addresses of the network providersenabling policyholders to visit the website of the respective hospitals for upto date information at any given point of time.
6. AllInsurersshall amend their Service Level agreements (SLAs) with the Network Hospitals toensurehospitals provide the above data for publication on Insurers website.
7. Thepolicyholders desirous of knowing the above details shall be able to access allthe above information on visiting the website of their Insurers.
8. Theabove directions shall come into effect from 01st April, 2021 andthe data for financial year ending 31st March, 2021 shall bepublished by 30th June, 2021.
9. Theabove instructions are issued under the powers vested with Regulation 31 (e) ofIRDAI (Health Insurance) Regulations, 2016.
(T LAlamelu)
Member(Non Life)
