Clinical Audit
Health insurance in India is largely 'fee' driven. It is very often perceived, and rightly so, that a
person who proclaims he/ she has health insurance cover is at risk of being over investigated and
over treated.
Insurers are not involved, at least not yet .in quality and/ or consumer cost of service rendered.
True, it does not matter to Ops or claims but ask customer service and marketing depts, it does
matter a lot!
Why is audit important?
A large segment of health insurance policies are NOT renewed (even in the second
year). Poor quality of care among network hospitals as well asexorbitant cost to
the consumer are the cited reasons for non-renewal.
Standard of care received in nursing homes and hospitals can often be
substandard. Clinical audit play a pivotal role in meeting and exceeding health
care standards by evaluating the current level of care and setting future goals.
Clinical Audit of Health claims
Simply put, clinical audit is review of performance to ensure that what should be
done is being done, and if not use it as a framework to enable improvements.
Clinical audit is 'Systematic, critical analysis of the quality of medical care,
including rational deployment of procedures used for diagnosis and treatment,
to help to provide reassurance that the best quality of service is being achieved,
having regard to the available resources.'
- Clinical audit can assess:
- Infrastructure - type of resources available; enough to deal with the case in question
- Process - what is done to patients? Appropriateness of the clinical approach; this can also point to subtle fraud!
- Outcome - the result of clinical interventions. It helps to estimate potential of readmission due to faulty treatment. Inappropriately treated patient will mean higher morbidity leading to repeat admissions for the same complaint. For the insurer, more payouts!
