Standard Operating Procedure and Checklist for Surprise Visits to Empanelled Hospitals · U-16012/268/2025-SST(E-1534916)

File No. U-16012/268/2025-SST(E-1534916) 25-06-2026 CIRCULAR Subject: Standard Operating Procedure (SOP) & Checklist for Surprise Visits to Empanelled Hospitals – reg.

  Enclosed herewith is a copy of the Standard Operating Procedure (SOP) and Checklist for Surprise Visits to Empanelled Hospitals for adoption and compliance by all ESIC/ESIS Institutions.

  The SOP and Checklist have been formulated to streamline the process and ensure uniformity, transparency and timely decision-making across all locations.

  This is issued for information and necessary action.

Encl.: Standard Operating Procedure (SOP) & Checklist.

(Dr. Bijoy Chandra Deka) Deputy Medical Commissioner (SST)

Copy to:

1. PPS to DG/FC/CVO for information.
2. Zonal Insurance Commissioners / Zonal Medical Commissioners for information.
3. All ESIC/ESIS institutions.
4. Website Content Manager to upload on website.
5. Rajbhasha Shakha - for Hindi translation.

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SOP & Checklist for Surprise Visit to Empanelled Hospitals

STANDARD OPERATING PROCEDURE (SOP)

1. Title SOP for Conduct of Surprise Visit /Inspection of Empanelled Hospitals

2. Objective The objective of this SOP is to establish a uniform, transparent, and accountable mechanism for conducting surprise visits / surprise inspections of empanelled hospitals to assess:

• Availability and quality of medical services
• Compliance with ESIC/CGHS norms and empanelment terms and conditions.
• Availability of infrastructure, manpower, and equipment.
• Adherence to package/protocol guidelines
• Quality of patient care and beneficiary handling
• Prevention of Fraud, irregularities, overcharging, denial of services, or misuse of empanelment

3. Scope This SOP shall apply to all empanelled hospitals / diagnostic centres / specialty centres under the organization. The inspection may be conducted for:

• Routine monitoring
• Complaint-based verification
• Random quality assessment
• Verification of infrastructure / manpower / specialty services
• Verification of treatment/services being claimed under empanelment
• Post-empanelment compliance review
• Renewal / continuation review support

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• Patient Identity & Eligibility Checks: Cross-verify the beneficiary’s e-Pehchan card, Aadhaar, and dependent certificates against ESIC databases. Ensure the patient has valid, active coverage and is correctly identified to prevent ghost or proxy patients. Biometric Authentication can be used.
• Unauthorized Cash Charges: Confirm cashless treatment for authorized services. Verify that no additional amounts (e.g., for medicines, sundries, or room upgrades not in the referral) were collected directly from the patient or their attendants.
• Compliance To MoU: Check for chronological clinical sheets, signed detailed discharge summaries, and utilization certificates. Ensure high-cost drug invoices (typically ₹5,000 or more or as defined by ESIC) match the items billed.
• Whether General bed or ICU- Whether the patient is in General bed or ICU at the time of surprise visit.
• Random Calling of Patient: Randomly calling discharged patient to match the documented date of Admission and discharge and Physical admission & Discharge.
• Whether the Hospital is providing meals to patient etc.
• Availability of Specialist/Superspecialist for which Patient has been referred and their notings /advice/signature in progress notes.
• Availability of Specialist/Superspecialist of the Specialities for which Hospital has been empanelled.

4. Constitution of Inspection Team: Nominated by ZMC - The inspection team shall ordinarily consist of 2–4 members, depending on the nature of inspection.

5. Frequency of Surprise Visit: Minimum 2 surprise inspections per month

6. Focus Areas: ICU cases, billing practices, Manpower and Equipment availability & functioning, Superspecialist doctor & Infrastructure (if applicable), referral compliance, and fraud detection.

7. Records to Review: Medical records, billing, referral forms, ICU records.

8. Post-Inspection: Submit report to Zonal Office with findings and recommendations. Zonal MC will examine the report and give directions to the RD to take action accordingly.

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9. Timeline for Compliance by Hospital If deficiencies are found and are considered rectifiable, the hospital may be directed to submit: Compliance report within 7–15 days along with supporting documents / photographs / certification, wherever necessary Failure to comply may invite further action.

10. Post Inspection Action: May Issue Warning, Advisory, recovery, suspension, or de-empanelment based on severity.

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INSPECTION CHECKLIST

A. Basic Details

1. Hospital Name, address and Registration details
2. Empanelment Valid up to
3. NABH Accreditation/other licenses
4. Date & Time of Inspection
5. Inspection Team Members with designation

B. Patient Care

C. Clinical Practices

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D. ICU Review

E. Referral Audit

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F. Billing

G. Fraud Checks

H. Records

I. Final Observations of Inspection Team:

J. Recommendations of Inspection Team:

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Signature with Name & Designation of all the Committee Members Date:

References:

• ESIC Referral Policy 2023 and its amendments (latest: 01.07.2025, No. U-16/30/649/2020-SST).
• Streamlining of Payment Process circular dated 27.01.2026 (No. U-16012/46/2025-SST).
• Revised CGHS Rate Circular dated 03.10.2025, adopted by ESIC vide circular dated 07.11.2025.

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