New Guidelines for CGHS Empanelled Healthcare Organizations has been issued to stop Fraudulent Billing and Overcharging by HCOs
Table of Contents
Complaints Regarding Fraudulent Billing and Overcharging by HCOs
E. Office No. 8290201
F.No.5-36/CGHS (HQ)/HEC/20242612-37
Central Government Health Scheme, Headquarter
Ministry of Health and Family Welfare, Govt. of India
CGHS Bhawan, Sector – 13, R. K. Puram, New Delhi 110066
(Hospital Empanelment Cell)
Dated: 19 December, 2024
Advisory to All CGHS Empanelled Healthcare Organizations (HCOs).
It has come to the Directorate’s attention that certain Healthcare Organizations (HCOS) are engaging in fraudulent activities when submitting bills on the NHA portal. Complaints have also been received from beneficiaries regarding overcharging, denial of treatment, and other grievances. To address these issues, the following guidelines are issued for strict compliance by all HCOS empanelled under CGHS:
1.Provision of Services
HCOS must not deny services to any eligible CGHS beneficiaries. Beneficiaries/ In cases of patient death or when the patient is in a coma, the signatures of the beneficiaries’ attendants, along with their mobile numbers, must be obtained on the final bills for all Indoor and OPD services, including daycare, laboratory services, dialysis, etc.
2.Reporting Requirements
HCOS must report the following cases to the respective Additional Director’s office within 24 hours via email to the dedicated email IDS (to be shared by the respective Additional Directors):
- Details of non-referral cases.
- Emergency admissions and consultations.
- Direct visits and admissions of beneficiaries aged 70 years and above, including inpatient card details.
Cases that are not reported to the Additional Directors (ADS) will not be processed for approval.
3.Bed Availability Display
- HCOS must prominently display the availability of beds in various wards and ICUS for the benefit of visiting patients.
4.Ward Entitlement
- Beneficiaries must be provided their entitled ward category. Allocating a lower category is unacceptable.
5.Prescription Standards
- Prescriptions must be written in generic names and in capital letters. HCOS must not insist on specific brands.
6.Acceptance of Medicines
- HCOS must accept medicines supplied by CGHS, which are procured through standardized procurement processes, ensuring proper cold chain maintenance.
- If an HCO declines to accept CGHS-restricted medicines, they must provide the purchase invoice for the medicines. In such cases, reimbursement will be made based on the purchase invoice cost.
7.Implant/Device Choices
- If a beneficiary selects an implant priced above the CGHS ceiling rate, informed consent must be obtained, clearly stating that the additional cost cannot be claimed from CGHS. This consent must be attached to the bill.
8.Information Display
- All HCOS must display the following details on their notice boards and in other prominent places:
| Empanelled under | CGHS City |
| Charges | As per CGHS approved rates |
| Beneficiaries eligible for Credit | Pensioners, Ex-Members of Parliament, Sitting Members of Parliament, Freedom Fighters, Serving CGHS/DGHS/Ministry of H&FW Employees, Serving employees in emergency & Other Categories of CGHS Cardholders (as notified by the Government) |
| Name and contact of the Nodal Officer | – |
| Escalation Matrix | – |
| Email Id of Additional Director CGHS | – |
9.Nodal Officer Updates
- Any changes in the Nodal Officer’s details (name or phone number) must be immediately communicated to the respective Additional Director.
10.Portal Data Entry
- Only the beneficiary’s phone number must be entered in the BIS/TMS portal.
11.Daily Photo Uploads
- Geo-tagged photos of all admitted (IPD) cases must be uploaded to the TMS portal daily.
- For OPD cases, photos taken on the same day must also be uploaded.
12.CGHS Help Desk/Kiosk
- All HCOS must establish a CGHS Help Desk/Kiosk on their premises to facilitate beneficiaries.
13.CGHS Card Handling
- HCOS are strictly prohibited from collecting or retaining the hard copy of the CGHS card of any beneficiary.
14. Adherence to Package Rates
- HCOS must not collect any amount from beneficiaries beyond the package rates prescribed by CGHS.
15.Fraudulent Billing
- Submission of fake bills or forged documents by any HCO will be considered financial fraud. Appropriate legal action will be initiated, including the filing of an FIR against the institution, in accordance with the law of the land.
Failure to adhere to these instructions will result in serious consequences, including de-empanelment or blacklisting, as per the provisions of the Memorandum of Agreement (MOA). All empanelled HCOS are directed to ensure strict compliance with the above guidelines.
(Dr.Satheesh Y.H)
Director, CGHS
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