Private hospitals in Maharashtra mourn over cancer insurance claims

MUMBAI: The government and private medical centers associated with the MPJAY insurance plan, funded by the state, are in disagreement over the misuse of cancer treatment packages. In the first crackdown of this kind, the government has rejected more than a hundred insurance claims in private hospitals across the state to curb alleged profits. Cancer specialists responded to the action, taken more than two months ago, and say they are being pressured to use obsolete, suboptimal and cheaper treatment plans according to MPJAY, which serves 2.25 of the poorest families in the world. state.

Procedures for cancer, including radiation therapy (costs up to Rs 1.5 lakh), have accounted for the largest number of medical claims under MPJAY (Mahatma Jyotiba Phule Jan Arogya Yojana) since its inception. A state official said several private hospitals are probably trying to recover their investments by milking the state plan.

The confrontation between the state and hospitals has affected dozens of cancer patients, who are forced to seek funds or queue at government facilities to complete the treatment. Physicians claim that they have been told repeatedly to justify treatment options, or even worse, even that they have been advised about the best way to treat cancer patients by third-party administrators (TPAs) during prior authorization. Insurers, on the other hand, claim to have observed an abuse of high-end radiotherapy packages, ranging from Rs 75,000-Rs 1.5lakh, presumably recommended to most patients, whether they are indicated or not, thus eliminating all the insurance coverage of families.

At two Thane centers, where the claims of nearly 45 patients have been rejected since April, doctors said several have not returned to complete the treatment. For a 32-year-old patient with a rare cancer of the nasal cavity, his radiation oncologist advised imaging-guided radiotherapy (IGRT) with intensity-modulated radiation therapy (IMRT). It was suggested given the proximity to critical normal structures. But the TPA suggested that we only provide IMRT, which any qualified doctor would say was not optimal, the doctor said. Despite several rounds of communication with the TPA, approval never arrived.

The patient said that she could no longer pay for the treatment and left. Why should insurers suggest a treatment, which is only a doctor's prerogative?

The difference of opinion not only leads to claims being rejected, but to crucial delays for patients. At the Vivekananda Cancer Hospital in Latur, Dr. Pramod Tike said that approximately 30% of prior authorization approvals have received comments as incorrect treatment selected. For a 30-year-old patient with head and neck cancer, who needed external beam radiation, TPA insisted on brachytherapy. Why should we subject our patients to therapy with side effects when there are safer and more advanced options available, he said.

Refuting that any claim was rejected, Dr. Sudhakar Shinde, operations director of MJPJAY, said: Our analysis shows that the consumption of packages above Rs 1 lakh is unusually high in private centers. Hospitals were simply told to adhere to standard treatment protocols, which are followed in first-level facilities such as the Tata Memorial Hospital (TMC).