The Central Government Health Scheme provides comprehensive health care facilities for central government employees and pensioners and their dependents residing in CGHS covered cities. The ministry’s office memorandum also issued detailed guidelines related to treatment and billing in respect of CGHS beneficiaries:
1) Prescriptions issued by specialists of empanelled hospitals in respect of medicines must mention the generic name, according to the memorandum.
2) Specialists of empanelled hospitals shall not prescribe medicines of equivocal value nor items that come under the category of nutritional substances, it added.
3) Antibiotic policy (of the hospital) must be followed and care should be taken for judicious use of high-end antibiotics including anti-fungal agents. High-end anti-biotics including antifungal agents should preferably be used on recommendations of a Committee constituted for the same, it added.
4) There are prescribed guidelines for use of IV Albumin and they should be adhered to.
5) Disposable items must be utilised in optimum quantity, as per the official memorandum.
6) Medicine is a branch of science and it should be practiced scientifically only, the ministry said.
a) The ministry further added that the investigations and treatment provided to the patient must be based on the differential diagnosis and provisional diagnosis arrived at on the basis of complaints, history of the patient, and clinical examination findings that must be documented.
b) Investigations that are repeated must add value to the treatment or be commensurate with the treatment.
c) Well established form of therapy should be used. Procedure/drug on trial should not be used.
d) If a new or newer form of drug/procedure is used, it should be specifically indicated for that particular patient because of the decisive superiority over the existing drug/procedure.
Submission of the hospital bill
The Ministry of Health and Family Welfare said that the documents in the bill should be arranged as per the following order
a) Copy of CGHS Card
b) Copy of Permission Letter in non-emergencies / beneficiaries up to 75 years of age
c) Emergency Certificate – with details
d) Copy of the Discharge Summary- in detail
e) Copy of valid NABH/NABL certificate
f) Hospital Bill for payment – consolidated followed by break-up bill in chronological order
g) Legible Copy of day-to-day medical notes signed by the treating doctor and progress chart in chronological order
h) Copies of the investigation in chronological order
i) Copy of invoice pertaining to implant along with sticker if any- even if hospital purchased in bulk, a copy of invoice relevant to the batch number shall be enclosed.
j) Any other relevant document
In case documents are not arranged in proper chronological order, the bill may be returned.
“CGHS scrutinises the credit bills received in respect of the above items and if, it is considered that there are unjustified use of certain items, they shall be deducted from approved bills. CGHS also reserves the right to take suitable action in case of deviation,” the ministry added.