Health benefits package selection in oncology: a clinical audit of palliative chemotherapy for breast cancer in an Indian health insurance scheme.

backgroundThe effective operation of health insurance requires functioning administrative processes, including appropriate filing for reimbursements. The unlisted palliative care package is one of the most utilized oncology packages within Indian state health insurance schemes. We conducted a clinical audit to evaluate the appropriateness of claims for this package for patients with breast cancer.

methodsWe obtained documentation submitted to support a random sample of insurance claims for the unlisted palliative care package for 50 patients (total) from one public and one private hospital, cataloged the available records, and assessed the appropriateness of package selection using clinical guidelines from India's National Cancer Grid. Where sufficient documentation was available, we also assessed the clinical appropriateness of care. We also examined whether these patients received relevant care at other hospitals that participate in the scheme and, for five purposefully selected patients, whether additional documentation had been submitted alongside other claims.

resultsClaims for 45 of the 50 patients had sufficient documentation to assess whether the selected package was appropriate. Among these 45 claims only 33% were selected in accordance with guidelines; the public hospital had a relatively higher share of appropriate selections. In many cases (21 claims), the palliative care package was selected for adjuvant therapy and targeted therapy. While more than half of the sampled patients had multiple related encounters and sometimes received care from multiple hospitals, reviewing additional claims did not affect our conclusions.

conclusionClaims for the palliative chemotherapy unlisted package often had deficient documentation and were inappropriately selected.