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Circular
Ref. No:IRDAI /HLT/CIR/MISC/145/06/2020 Date:10-06-2020
Standards for hospitals in the provider network – Disclosure of Quality Parameters

To

All Insurers and TPAs,

Re: Standards for hospitals in the provider network – Disclosure of Quality Parameters

1.    Reference is invited to the provisions of Regulation 29 (iv) of IRDAI (Health Insurance) Regulations, 2016 wherein Insurers are directed that they shall keep the insured informed of the list of Network Providers and display the same on their website. Such list shall be also displayed geography wise and updated as and when there is any change in the Network providers.

2.    Reference is also invited to the provisions of Clause (dd) of Schedule I read with Regulation 23 of IRDAI (TPA-Health Services) Regulations, 2016 wherein it is specified that TPAs shall disclose the list of network hospitals with whom it has valid agreement to policy holders, prospects and general public.

3.    With respect to the Network Providers engaged for rendering cashless services, Insurers, shall also disclose the following details of the network providers ( as per Table – A and Table – B) and these details shall be updated as at 31st March of every financial year and be disclosed by 30th June.

NAME OF THE HOSPITAL ------

ROHINI Id

Address

**Information as at --------

TABLE - A

 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).

** The date as on which the data is valid, as received from the network provider, shall be stated by the insurer. Wherever the data is NIL the same shall be specified.

 

TABLE - B

 

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
RATIO

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
ADMISSION
TIME

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
Denominator: Total number of medical inpatient discharges (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)
FOR SURGICAL CASES

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
Denominator: Total births(number of deliveries) in the hospital in same time period relating to insurer
x100

(As per the calculation of Insurer taking into account all the respective admitted cases in the preceding financial year.)

 

4.    All TPAs shall provide the link of the insurance company where the said information is available.

 

5.    TPAs and Insurers shall also disclose the web addresses of the network providers enabling policyholders to visit the website of the respective hospitals for up to date information at any given point of time.

 

6.    All Insurers shall amend their Service Level agreements (SLAs) with the Network Hospitals to ensure hospitals provide the above data for publication on Insurers website.

 

7.    The policyholders desirous of knowing the above details shall be able to access all the above information on visiting the website of their Insurers.

 

8.    The above directions shall come into effect from 01st April, 2021 and the data for financial year ending 31st March, 2021 shall be published by 30th June, 2021.

 

9.    The above instructions are issued under the powers vested with Regulation 31 (e) of IRDAI (Health Insurance) Regulations, 2016.

 

 

(T L Alamelu)

Member (Non Life)

 

Insurance Regulatory and Development Authority of India. All Right Reserved.