EXPERT MEDICOLEGAL CONSULTANCY (EMC) is a firm providing and co-coordinating the various insurance auxiliary services in the health insurance sector since over a decade. EMC has been associated with Government Undertaking Insurance Companies (The New India Assurance, The Oriental Insurance, United India and The National Insurance Co. ltd.) as well as the Private players in insurance field in the capacity of panel medicolegal consultants. We have our presence in Maharashtra, Bangalore and will very shortly commence our operations in Delhi region.

HOSPITAL VISITS FOR PATIENT VERIFICATION (Spot investigations)
It is a fact that many of the insured who have availed cashless facilities from the TPAs, misuse the facility provided to them by admitting their parents or any other relative who is not covered by such cashless facility. Also, there are instances when the patients are not at all admitted, still the bills are raised and settled in cashless scheme. It is also a fact that the hospitals empanelled by the TPAs try to cook up the documents in some way or the other in order to raise exaggerated bills to the TPAs. In order to put a check on these and such acts on the part of those involved, we are providing the services of HOSPITAL VISITS to the insurers.

We are visiting the hospitals to cross check and verify the hospitalisations of the patients on cashless basis. On analysis of the obtained data, we could pinpoint many instances of illegal and unethical acts & irregularities on the part of the hospitals, patients and also some TPAs serving the corporate as well as individual policies.

We have our trained team which visits the various hospitals for confirming the hospitalization, the authenticity of the insured admitted in the hospital, the class and type of room in which the patient is admitted, the proposed plan of management, approximate expenses projected by the hospital and the amount authorized or settled by the TPAs . We do it on daily basis without any delay so that we get an authentic information regarding hospitalization of the patients under cashless facility. For this, the insurers have to instruct their TPAs to send the list of all the admitted patients daily to our e-mail giving details about the name of the patient, the hospital in which he is admitted or going to be admitted, the scheduled date of admission.

Once we receive this list every morning, members of our team personally visit those hospitals and verify the relevant facts, report them in the formats provided. The details of all these visits throughout the city carried out that day is compiled in an excel sheet and we forward it to the insurers on daily basis with our comments and observations, whether the hospitalization is justifiable or not and if not then the reasons thereof. This helps the insurers to have the entire picture of the claims under its health policies on day to day basis and also helps prevent any illegal advantage being planned either by the patient or the hospitals.

TPA AUDITING
This is another method used by the insurers to keep a check on the claim ratio in health policies. We perform a detail audit of all the files both for corporate clients of the insurers or for individual policies. The tailor-made policies designed to suit the needs of corporate clients cover almost every illness and all possible circumstances. But still with our expert team of trained doctors auditing each and every file of a settled claim, we could reveal many irregularities in claim settlements, which have led to recovering the paid amounts from the concerned TPAs. In the process we also verify the bills in view of the tariff agreements the TPA’s have with their network hospitals. With our vast experience of over a decade, we are very confident of performing TPA Audits- both technical and system audits. Our team of medicos is specially trained for the purpose. One such sample audit report is annexed herewith.

CLAIM INVESTIGATIONS AND FRAUD DETECTION
Many of the claims need to be investigated for the fraud committed either by the insured or the hospital or the TPAs. The present investigators available for the purpose do not have any background knowledge of Forensic Sciences and support of medical doctors, which definitely is needed in most of the claim investigations. During claim investigations our aim is:

• To develop a SOP about the criteria to label a claim as suspicious.
  
• Identifying fraudulent insurance claims with high degree of accuracy even with large claim volumes.
  
• Quickly approve legitimate insurance claims out of these.
  
• Thereby improving the productivity and accuracy of claim handling.
  

Our trained team of investigators backed by our management of senior and experienced forensic experts has proved their efficacy in the past. We hope to provide our services to your insurance company.

HOSPITAL INFRASTRUCTURE AUDIT
The present scenario is such that, the TPAs empanel the hospitals by applying their own criteria. The patient is admitted directly in the hospital for cashless facility, the hospitals raise the bills to the TPAs and the TPAs settle the hospital bills. In this whole process there does not appear any supervisory role of the insurers who is actually paying for the hospital bills. · Many times it is observed that the hospitals that are empanelled are sub standard and do not comply with the standards set forth by the TPAs. But still such hospitals are empanelled by the TPAs.

• Also, there are instances where some hospital are black listed by the TPAs for the frauds committed by them previously. However, these hospitals start their functioning anew with a different name and again apply to the TPAs for empanelment.
• Also, sometimes the patient is admitted in the hospital which is not empanelled by the TPA, Operated there but the bills are raised from the hospital that are empanelled by the TPAs in order to avail the cashless facilities.
• There are instances where the hospital has two tariff cards, one for the patients admitted under cashless facility and one for those who are paying out of their pockets. Invariably, the charges for those availing cashless facilities are higher. In such circumstances, it becomes necessary to get both the tariff rates from the hospitals and compare it with the agreed tariff with the TPAs.

To keep a check on all these activities, we propose to have the HOSPITAL AUDIT on behalf of the insurers. This will not only help keep a check on such unscrupulous activities but in long run improve the image of the insurers as well as improve the quality of medical facilities provided in the city. In this audit our trained staff will personally visit the hospitals and thoroughly check each and every facility claimed by the hospital, including the qualifications of the staff, the registration of the hospitals, the space, the nursing staff, the equipments and machinery available etc.

PRE-INSURANCE HEALTH CHECK UP
This particular service has proved beneficial to the insurers by putting a check on the policy provisions right at the time of inception of the policy. The diseases for which the proposer is prone or at risk are deleted from the scope of the policy right at the very beginning. Even though with the criteria of inclusion of pre-existing diseases after 4 claim free years, many patient do not reveal the pre-existing diseases and get the claims of major amounts settled. We are consistently doing the pre-insurance health check up for the insurers in Mumbai for last 7 years with fantastic results and very positive impact on the claim ratio as regards mediclaim policies. We maintain a strict vigil on the day to-day functioning of the empanelled centers and take strict action against the erring hospitals and the defaulter doctors. The identity of the proposer is always verified with the help of a valid photo id card, which includes either a driving license, PAN card, Voter ID card or the photo identity card provided by respective employers. After a thorough scrutiny of the findings of clinical examination and the investigation reports, we suggest relevant exclusions to be levied while issuing the policy. This way we have successfully excluded many major diseases, which had the potential to culminate into huge insurance claims.

LEGAL CELL
Our panal of advocates, medicolegal consultants, doctors, provide a spectrum of legal services in MACT / CONSUMER FORA / OMBUDSMAN / CIVIL COURTS / PA CASES / PROFESSIONAL (MEDICAL) INDEMNITY INSURANCE MATTERS ETC. Apart from effectively drafting and pleading various cases our team and back office is trained in legal research. Once we could finalize the packages as per the needs of the insurers, we are confident to provide these services to them.