Jaipur: Rajasthan Govt Health Scheme has flagged 479 suspected cases in which private hospitals allegedly split diagnostic claims to bypass mandatory pre-authorisation for OPD tests costing more than Rs 2,000.The cases, detected through one month of data analysis, are linked to 238 beneficiaries. Around 50 private hospitals and 60 doctors across Rajasthan are now under investigation, with the highest number of suspected cases reported from Jodhpur, Jaipur, Udaipur and Alwar.A senior health department official said the preliminary scrutiny suggests that some hospitals called patients three to four times for the same illness and conducted diagnostic tests separately, instead of prescribing them together. This allegedly helped keep individual claims below the Rs 2,000 threshold and avoid the RGHS pre-approval process.The health department’s revised OPD investigation guidelines came into force on July 13, 2026, and apply to all private empanelled hospitals, diagnostic centres, the third-party administrator and other stakeholders.Under the rules, routine OPD investigations costing up to Rs 2,000 can be prescribed and conducted without prior approval. For tests exceeding Rs 2,000, hospitals and doctors must obtain pre-authorisation through the RGHS portal before proceeding.Emergency cases are exempt, but treating hospitals must upload proper clinical documentation and justification on the portal.For pre-authorisation, hospitals are required to submit the OPD prescription or consultation slip, medical history, clinical findings, previous investigation reports where applicable, and clear justification for the proposed tests.“Prima facie, there is suspicion that tests and claims were split with the objective of obtaining higher reimbursements and avoiding pre-authorisation,” the official said.RGHS project director Nidhi Patel said the practice also caused avoidable inconvenience to patients, including women and elderly beneficiaries, who were repeatedly called to hospitals in the name of separate tests.She said the scheme is conducting a detailed investigation into all flagged cases. If any hospital or doctor is found to have deliberately split tests or claims to secure higher reimbursements or evade approval rules, strict action will be taken as per norms.
