Strict Verification and Scrutiny of Documents for Super Speciality Treatment (SST) Cases in ESI

Introduction

The Employees' State Insurance Corporation (ESIC) has issued a new directive aimed at tightening the verification and scrutiny process for Super Speciality Treatment (SST) cases. This move is intended to prevent fraudulent activities and ensure that genuine insured persons (IPs) and their families receive the medical benefits they are entitled to. Below, we provide a comprehensive overview of the key measures introduced in this notification, identified as File No. U-16012/392/2022-SST, dated 25-07-2024.

Key Measures Introduced

1. Thorough Document Checks: All referring locations must conduct detailed checks, especially for high-cost treatments where the diagnosis date is after the date of registration in the ESIC system.

2. Increased Scrutiny: Enhanced scrutiny of cases to identify any potential collusion between employers and pharmaceutical companies.

3. Stringent Assessment Criteria: Maintain strict criteria for approving SST on a case-by-case basis to ensure only genuine cases receive benefits.

4. Regular Audits and Monitoring: Implement regular audits and monitoring of cases and referrals to detect and prevent fraud.

5. Regional Directors' Role: Regional Directors are required to conduct detailed document verification for all new cases and provide justification from the competent authority to the HQ office, ensuring the authenticity of the patient and the IP.

Background and Context

As per the directions of the Hon'ble High Court, ESIC is mandated to provide SST to insured persons and their family members from the first day of their employment. However, instances of fraud, especially in expensive and lifelong treatments like Enzyme Replacement Therapy (ERT) and cancer cases involving proprietary expensive Non DG ESIC RC drugs, have necessitated these stringent measures.

Implications for ESIC User Locations

All ESIC user locations, including hospitals, medical colleges, and regional offices, are required to adhere strictly to these new guidelines. This will ensure the integrity and effectiveness of the SST provisions, safeguarding the system against fraudulent practices and ensuring that genuine IPs and their families receive the benefits they are entitled to.

Conclusion

The new verification and scrutiny measures for SST cases, as outlined in the ESIC notification (File No. U-16012/392/2022-SST), are crucial steps towards maintaining the integrity of the ESIC system. By implementing these measures, ESIC aims to prevent fraud and ensure that only genuine cases benefit from the SST provisions.

For more detailed information, please refer to the official notification number U-16012/392/2022-SST.

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Strict_Verification_and_Scrutiny_of_Documents_for_Super_Speciality_Treatment_(SST)_Cases_in_ESI.pdf