CMHIS billing dispute: Nagaland Health Protection Society intervenes

Dimapur, July 8 (MExN): The Nagaland Health Protection Society (NHPS) has stepped into a contentious billing dispute involving a prolonged Neonatal Intensive Care Unit (NICU) admission. The clarification comes in response to a grievance raised by a beneficiary under the Chief Minister Health Insurance Scheme (Employees & Pensioners) [CMHIS (EP)], who was billed an additional amount of Rs 5,15,704 by a hospital for the course of treatment. It noted that only Rs 1,63,975 was processed and settled as the eligible claim amount under the Scheme.

In a statement issued by Thavaseelan K, IAS, CEO of NHPS, the Society confirmed that it has taken up the issue with the concerned empanelled hospital and has advised it to process the claim in accordance with the applicable CMHIS package provisions and guidelines.

Reiterating the provisions under the CMHIS, the NHPS detailed that NICU bed charges are covered under the approved package rates, and the Scheme also provides coverage for Paediatric Care for Newborns wherever applicable. Additionally, separate add-on packages are available for oxygen, laboratory, and diagnostic investigations. The Society clarified that medicines are reimbursable through the Open Billing mechanism, where claims for drugs are settled as per the National Pharmaceutical Pricing Authority (NPPA) ceiling or on the actual cost of the drugs.

It further emphasised that consultation charges are included within the approved package rates and are not payable separately. Additional consultation charges are admissible only in cases of approved cross-consultations, where such add-on provisions are specifically provided for under the Scheme Guidelines.

Underlining the principle of cashless treatment, the NHPS stated that no additional amount shall be recovered from a beneficiary except for non-payable items as per the IRDAI guidelines such as diapers and toiletries and for instances where the beneficiary voluntarily opts for a higher room entitlement or higher-value implants beyond the Scheme entitlement. In all other circumstances, the Scheme mandates the provision of cashless treatment, and recovery of any outstanding amount from the beneficiary is not permissible.

The Society also reminded the hospital of its obligations under the Empanelment Agreement, noting that at the time of empanelment, the hospital executed a Memorandum of Understanding (MoU) with the State Health Authority, having accepted the approved package rates and the Scheme Guidelines. By virtue of this agreement, the hospital undertook to provide cashless treatment to all eligible AB PM-JAY/CMHIS beneficiaries in accordance with the approved package rates and Scheme provisions.

The NHPS has emphasised that all applicable package provisions, claims settlement and approval processes available under the CMHIS Scheme must be fully explored and appropriately utilised before concluding that any expenditure is not covered under the Scheme.

Reaffirming its commitment, the NHPS stated that it remains dedicated to ensuring that all empanelled healthcare providers adhere to the Scheme Guidelines. The Society has requested both beneficiaries and empanelled hospitals to contact the NHPS Team as the first point of contact in the event of any concern or difficulty. Early communication, the Society noted, enables NHPS to work closely with all concerned parties to facilitate a timely and amicable resolution, helping to minimise inconvenience and avoid unnecessary escalation.

AB PM-JAY and CMHIS beneficiaries may reach the NHPS Toll-Free Helpline at 1800-202-3380 by call or WhatsApp to seek assistance or register a grievance.

Hospital clarifies; cites consent, IRDAI norms & NHPS intervention

The Eden Medical Centre on Wednesday issued a clarification regarding the treatment and billing of a premature baby, stating that the parents had signed a consent form agreeing to bear charges not covered under the state insurance scheme. 

The Eden Medical Centre Management in its statement confirmed that the baby, born at approximately seven months of gestation weighing only 920 grams, required immediate admission to the Neonatal Intensive Care Unit (NICU) from birth. Owing to the baby’s critical condition, intensive monitoring and specialized treatment were provided continuously for 64 days by a dedicated team of pediatricians, nurses and support staff.

Throughout the hospitalization, the baby required round-the-clock intensive care, including continuous oxygen therapy, with or without Continuous Positive Airway Pressure (CPAP) support, specialized neonatal monitoring, medications, laboratory investigations and comprehensive nursing care. These interventions were medically necessary and played a vital role in the baby’s survival and recovery, it stated.

Under the CMHIS, the approved package for neonatal intensive care is Rs 1400 per day, covering doctor’s consultation, nursing care, ICU bed charges and phototherapy. However, the hospital noted that in addition, approved add-on services, including oxygen therapy, laboratory investigations, and other eligible services, are claimable in accordance with the scheme guidelines. Furthermore, as per the applicable guidelines of the Insurance Regulatory and Development Authority of India (IRDAI), certain nonpayable consumables, such as diapers, baby food and similar items, are specifically excluded from insurance coverage.

The hospital management stated that at the time of admission, the parents were clearly informed that the CMHIS package would not fully cover expenses arising from a prolonged NICU stay and that additional charges might be incurred. “They acknowledged this information and signed a written consent agreeing to bear any charges not covered under the insurance scheme. A copy of the signed consent form is available in the patient’s medical record,” it stated.

Following the baby’s stabilization, the child required transfer to another hospital for specialized pediatric surgical intervention. At discharge, the father informed the hospital he was unable to settle the outstanding amount immediately and requested additional time, which the hospital agreed to.

The hospital further revealed that it had formally approached the Nagaland Health Protection Society (NHPS), explaining the exceptional circumstances of the case and seeking guidance regarding the recovery of expenses exceeding the approved insurance package. The hospital subsequently received a response from NHPS advising that eligible package add-ons could be utilized to reduce the patient’s financial liability. Accordingly, the hospital is currently processing all eligible add-ons in accordance with CMHIS guidelines. “We are hopeful that, once this process is completed, the patient’s entire bill will be accommodated under the scheme,” the statement read.

During this period, the hospital made multiple attempts to contact the baby’s father to inform him that the matter had been referred to NHPS for guidance and resolution, it added. 

However, the hospital expressed concern over media statements made before the process could be completed or any final decision communicated. “Statements regarding the matter were made in the media that, in the hospital’s view, do not accurately reflect the facts of the case and have caused reputational harm to the institution,” the management said. 

“The hospital is presently obtaining legal advice regarding the publication of these statements and reserves all rights available to it under the law,” it added. 

The hospital reiterated its commitment to providing quality healthcare to all patients irrespective of financial circumstances while ensuring that all treatments and billing practices remain transparent, ethical, and in full compliance with CMHIS and Government of Nagaland guidelines.