Idle internal auditor patient  spots control gaps, entirely unnecessarily

Blogger: Ashutosh Pednekar

IA @ BCAS Blog #15

Empty vessels make most sound. Idle mind is devil’s workshop. And an internal auditor as a patient (me) in isolation ends up spotting service deficiencies, leading to control gaps  – quite unnecessarily and definitely unsolicited. So please bear with me and read this blog.

Covid struck. And it struck all of us at home. With my fever continuing by the evening of Day 4, the doctors decided that I needed to be hospitalised if fever did not subside through the night. Duly next morning I reached the hospital.  After a few inquiries I reached the Covid OPD and I was taken in quickly, after sighting my RTPCR report on my mobile. All usual examinations began. But along with the examinations, the admission process had to be completed. So with an IV attached to me, there I was, filling up the admission forms and digitally sending to the hospital number my Aadhar and my PAN information. (Control Gap No. 1 – the hospital had no process in place to assist a solo patient to fill up the forms).

I had a cashless insurance policy (courtesy my employer), but the hospital insisted that I pay a deposit of Rs. 50,000/-. And, for this, they expected a relative to come over to their office. I informed them that I am alone. Nobody could accompany me as all immediate family was Covid positive, and I did not want to risk of exposure requesting some friend or relative to accompany me. Ultimately, the girl with the credit card machine came over to the Covid OPD and requested (nay, insisted) that I hand over my card and the PIN to her so she could swipe it. I refused. She refused. I refused. She blinked first, when the OPD nurse told her that the machine could be sanitised. The girl had no qualms of holding my credit card in her hand to swipe it, but did not want me to touch the machine to enter the PIN. Sense prevailed ultimately, and payment went through. I was now officially an in-patient of the hospital with a number allotted!!!  I requested that I be allowed to pay through net banking. The girl said that it would be difficult as she would need to wait for the Unique Transaction Reference (UTR) to confirm my admission. (Control Gap No. 2 – the hospital’s refusal to embrace technology).

What foxed me in this admission process was the lack of trust between the hospital and the insurance company. The insistence on payment of an initial deposit, when a cashless insurance cover existed, defied logic. The hospital said that the deposit would be their succour, in the event the insurer did not pay the entire amount. I thought about it later that the deposit would be to cover expenses not covered by insurance. However, at that moment the realisation that it is “not entirely cashless” sunk in.  (Control Gap No. 3 – lack of communication by the insurer as well as the hospital with the customer. Both entities on their website mention the convenience of cashless; fact is contrary). I now fully comprehended the phrase – The devil lies (pun intended) in the detail!!

A few days later, (with some excellent medical care given to me) the Doctor-in-charge (DIC!!) said I could get discharged. Well, it wasn’t so simple. The process involved a chain of communication – the Covid ward informing the billing department; the billing department informing the corporate department since I was a cashless insurance patient; the corporate department informing the insurer’s TPA (third party administrator); the TPA authorising the payment and all the way back. You would assume all this would be seamless but in reality, far from it!!. After all there was a TAT that was promised to us when we took the insurance cover. Reality, alas is something else. I waited for eternity.

Almost six hours later, with utter exasperation, I approached the nurse of the Covid ward and requested her to inquire about the discharge status. She nonchalantly mentioned that the TPA process always takes 3 to 4 hours and, if information comes in late and the hospital’s corporate department had closed for the day (their day ends at 3 PM!!!), then I will have to spend one more night at the hospital. Shudder! That also implied adding a day’s charges I guessed. She also said that the hospital had intimated the TPA about 4 hours ago. I got my office colleagues to speak with the insurer, who spoke to the TPA and, wonders be all, the TPA representative called me up  to confirm that they had cleared the claim an hour ago. (Control Gap No. 4 – customer convenience and service timelines were disregarded by both, the hospital as well as the insurer. Did someone mention reputation risk? Both, apparently, were blissfully unaware of that.).

In all this, I got a call from an official of the hospital where he insisted to speak with my relative. I told him that I am the patient. He said he was aware of it but, as a process, he needed to speak to the relative. The relative had to visit his department. I told him that I was unaccompanied, and I was in the Covid ward eagerly waiting to go home. He simply declared that if my relative did not meet him, I would not be able to go home. Period. I tried explaining in English, Hindi and Marathi that I am a solo unaccompanied patient, and whatever paperwork that was to be done could be digitally done. He was puzzled and bewildered!! It was nigh impossible for him to accept that there could be a solo patient who, along with taking care of himself, had to do all paperwork too. Somehow, finally, it dawned on him, and he signed off digitally, asking me to send an e-mail confirmation on a particular aspect. Thankfully, with that the discharge process was concluded, and I was permitted to leave the hospital. (Control Gap No. 5 – the hospital had no process in place to deal with a solo unaccompanied patient).

The last piece of the item is that the hospital has withheld Rs.10,000/- and said they will repay it after 45 days in case the TPA has some adjustments to be done. Everything of my claim is done and dusted. I have confirmed with the insurer and there is nothing else left to be done. The hospital has a free float for 45 days.

All in all, an interesting and memorable experience! The internal auditor in me had to spot these control gaps. It set me thinking – over the past 18-20 months we have the #newnormal. And, here, a couple of well-established entities were clueless and had not moved on with the #newnormal. The hospital has to realize and provide for a process for solo unaccompanied patients who need to be cared for. Processes need to be redesigned. Similarly, the insurer also needs to have more trust in the hospital as well as the insured and redesign its processes to ensure cashless works, as intended and, the promised TAT is achieved.

Amidst all this, lest I forget, let me thank the entire Covid ward staff for all their help and care. They were wonderful.

The Blog solely reflects the personal views and opinions of the author(s).

8 thoughts on “Idle internal auditor patient  spots control gaps, entirely unnecessarily

  1. Harsh reality of inappropriate communication and co ordination between hospital and Insurance agency . The patient is the sufferer. Hope you have communicated about the ordeal to both institutions

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  2. Great points. There’s no doubt more users of institutions should be rating them. We need a simple app with basic metrics for this. Here’s a gap in the market here to develop.

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  3. Great piece of personal analysis Ashutosh. There will always be roles for the system analyst whilst process and communication lags the needs of its users. Glad to hear you are on the mend ..

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  4. Once an auditor always an auditor. I hope both the institutions take it as an awakening and bring the change .TPA process is really painful everyone hospitalised once go this through this.

    Like

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