Common use of Gradation of Offences Clause in Contracts

Gradation of Offences. On the basis of the investigation report/field audits, the following charges may be found to be reasonably proved and a gradation of penalties may be levied by the SEC. However, this tabulation is intended to be as guidelines rather than mandatory rules and the SEC may take a final call on the severity and quantum of punishment on a case to case basis. Penalties for Offences by the Hospital Case Issue First Offence Second Offence Third Offence Illegal cash payments by beneficiary Full Refund and compensation 3 times of illegal payment to the beneficiary In addition to actions as mentioned for first offence, Rejection of claim for the case De-empanelment/ black-listing Billing for services not provided Rejection of claim and penalty of 3 times the amount claimed for services not provided, to Insurance Company /State Health Agency Rejection of claim and penalty of 8 times the amount claimed for services not provided, to Insurance Company /State Health Agency De-empanelment Up coding/ Unbundling/ Unnecessary Procedures Rejection of claim and penalty of 8 times the excess amount claimed due to up coding /unbundling/Unnecessary Procedures, to Insurance Company /State Health Agency. For unnecessary procedure: Rejection of claim and penalty of 16 times the excess amount claimed due to up coding/unbundling/Unnecessary Procedures, to Insurance Company /State Health Agency De-empanelment Wrongful beneficiary Identification Rejection of claim and penalty of 3 times the amount claimed for wrongful beneficiary identification to Insurance Company /State Health Agency Rejection of claim and penalty of 8 times the amount claimed for wrongful beneficiary identification to Insurance Company /State Health Agency De-empanelment Non-adherence to AB PM-XXX quality and service standard In case of minor gaps, warning period of 2 weeks for rectification, for major gaps, Suspension of services until rectification of gaps and validation by SEC/ DEC Suspension until rectification of gaps and validation by SEC/ DEC De-empanelment

Gradation of Offences. On the basis of the investigation report/field audits, the following charges may be found to be reasonably proved and a gradation of penalties may be levied by the SEC. However, this tabulation is intended to be as guidelines rather than mandatory rules and the SEC may take a final call on the severity and quantum of punishment on a case to case basis. Penalties for Offences by the Hospital Case Issue First Offence Second Offence Third Offence Illegal cash payments by beneficiary Full Refund and compensation 3 times of illegal payment to the beneficiary In addition to actions as mentioned for first offence, Rejection of claim for the case De-empanelment/ De- empanelment / black-listing Billing for services not provided Rejection of claim and penalty of 3 times the amount claimed for services not provided, to Insurance Company /State Health Agency Rejection of claim and penalty of 8 times the amount claimed for services not provided, to Insurance Company /State Health Agency De-De- empanelment Up coding/ Unbundling/ Unnecessary Unbundling / Unnecessa ry Procedures Rejection of claim and penalty of 8 times the excess amount claimed due to up coding /unbundling/Unnecessary Unneces sary Procedures, to Insurance Company /State Health Agency. For unnecessary procedure: Rejection of claim and penalty of 16 times the excess amount claimed due to up coding/unbundling/Unnecessary Unnece ssary Procedures, to Insurance Company /State Health Agency De-De- empanelment Wrongful beneficiary Identification Rejection of claim Rejection of claim and De- and penalty of 3 times the amount claimed for wrongful beneficiary identification to Insurance Company /State Health Agency Rejection of claim and penalty of 8 times the amount claimed for wrongful beneficiary identification to Insurance Company /State Health Agency De-empanelment Non-adherence to AB PM-XXX quality and service standard In case of minor Suspension until De- gaps, warning period rectification of gaps and empanelment of 2 weeks for validation by SEC/ DEC rectification, for major gaps, Suspension of services until rectification of gaps and validation by SEC/ DEC Suspension until rectification of gaps and validation by SEC/ DEC State Health Agency De-empanelment order confirmed after 2nd showcause In case of de- empanelment, order for confirmation forwarded SEC Network Hospital Direction and return of Investigation Report Investigation Report by DEC First Showcause /Final beneficiary Identificati on Non- adherence to AB- NHPM quality and service standard All these penalties are recommendatory and the SEC may inflict larger or smaller penalties depending on the severity/regularity/scale/intentionality on a case to case basis with reasons mentioned clearly in a speaking order. The penalties by the hospital will be paid to the SHA in all the cases. Insurance SHA Other Sources

Gradation of Offences. On the basis of the investigation report/field audits, the following charges may be found to be reasonably proved and a gradation of penalties may be levied by the SEC. However, this tabulation is intended to be as guidelines rather than mandatory rules and the SEC may take a final call on the severity and quantum of punishment on a case to case basis. Penalties for Offences by the Hospital Case Issue First Offence Second Offence Third Offence Illegal cash payments by beneficiary Full Refund and compensation 3 times of illegal payment to the beneficiary In addition Full Refund and compensation 5 times of illegal payment to actions as mentioned for first offence, the beneficiary and Rejection of claim for the case De-empanelment/ or recovery of claims De- empanelment , black-listing listing/ and legal actions Billing for services not provided Rejection of claim and penalty of 3 times the amount claimed for services not provided, to Insurance Company /State State Health Agency Rejection of claim and penalty of 8 times the amount claimed for services not provided, to Insurance Company /State State Health Agency DeDe- empanelment , black-empanelment listing and legal actions Up coding/ Unbundling/ Unnecessary Unbundling / Unnecessa ry Procedures Rejection of claim and penalty of 8 times the excess amount claimed due to up coding upcoding /unbundling/Unnecessary Unneces sary Procedures, to Insurance Company /State State Health Agency. For unnecessary procedure: procedure Rejection of claim and penalty of 16 times the excess amount claimed due to up coding/unbundling/Unnecessary Unnece ssary Procedures, to Insurance Company /State State Health Agency DeDe- empanelment , black-empanelment listing and legal actions Wrongful beneficiary Identification Identificati on Rejection of claim and penalty of 3 times the amount claimed for wrongful beneficiary identification to Insurance Company /State Health Agency Rejection of claim and penalty of 8 times the amount claimed for wrongful beneficiary identification to Insurance Company /State State De- empanelment ,black-listing and legal actions identification to State Health Agency De-empanelment Non-Health Agency Non- adherence to AB PM-XXX XXXX XXXXXXX N UTTARAKH AND quality and service standard In case of minor gaps, warning period of 2 weeks for rectification, for major gaps, Suspension of services until rectification of gaps and validation by SEC/ DEC Suspension until rectification of gaps and validation by SEC/ DEC DeDe- empanelment , black-empanelmentlisting and legal actions All these penalties are recommendatory and the SEC may inflict larger or smaller penalties depending on the severity/regularity/scale/intentionality on a case to case basis with reasons mentioned clearly in a speaking order. The penalties by the hospital will be paid to the SHA in all the cases. Annex 7: Indicative List of Emergency conditions

Gradation of Offences. On the basis of the investigation report/field audits, the following charges may be found to be reasonably proved and a gradation of penalties may be levied by the SEC. However, this tabulation is intended to be as guidelines rather than mandatory rules and the SEC may take a final call on the severity and quantum of punishment on a case to case basis. Penalties for Offences by the Hospital Case Issue First Offence Second Offence Third Offence Illegal cash payments by beneficiary Full Refund and compensation 3 times of illegal payment to the beneficiary In addition to actions as mentioned for first offence, Rejection of claim for the case De-De- empanelment/ black-listing Billing for services not provided Rejection of claim and penalty of 3 times the amount claimed for services not provided, to Insurance Company /State Health Agency Rejection of claim and penalty of 8 times the amount claimed for services not provided, to De- empanelment Company /State Health Agency Insurance Company /State Health Agency De-empanelment Up coding/ Unbundling/ Unnecessary Procedures Rejection of claim and penalty of 8 times the excess amount claimed due to up coding /unbundling/Unnecessary Procedures, to Insurance Company /State Health Agency. For unnecessary procedure: Rejection of claim and penalty of 16 times the excess amount claimed due to up coding/unbundling/Unnecessary Unneces sary Procedures, to Insurance Company /State Health Agency De-De- empanelment Wrongful beneficiary Identification Rejection of claim and penalty of 3 times the amount claimed for wrongful beneficiary identification to Insurance Company /State Health Agency Rejection of claim and penalty of 8 times the amount claimed for wrongful beneficiary identification to Insurance Company /State Health Agency De-De- empanelment Non-adherence to AB PM-XXX quality and service standard In case of minor gaps, warning period of 2 weeks for rectification, for major gaps, Suspension of services until rectification of gaps and validation by SEC/ DEC Suspension until rectification of gaps and validation by SEC/ DEC De-De- empanelment