Three admissions in eight months. The audit hold came on the third.
🧑⚕️ Neha, 34, worked in automobile parts manufacturing. Her father, Rajendra Singh, 72, a retired government accounts officer, had a diabetic foot ulcer that had plagued him for fifteen years. Managed. Stable. October 2025: wound reopened with infection. Three-day admission, debridement, closed by November. January: stepped in a hole, wound reopened. Two-day admission, healed by February. April: new sock seam caused friction injury. Four-day admission, deep infection, MRI ordered. On discharge, a red stamp appeared: "RGHS Case Under Audit—Further admissions require pre-approval from RGHS Central Review Office."
🚨 The problem
RGHS consolidates multiple admissions within 12 months and flags them for "cost-review protocol" once they cross an unspecified threshold (the threshold itself was not stated in any document). The audit is routine—a reviewer confirms discharge summaries match bills. But the reviewer works with a queue. Pre-approval takes days. When a diabetic ulcer is a chronic recurring condition, and the next infection could happen anytime, a family is frozen: need admission, must wait for pre-approval, urgent infections don't wait.
🚀 How GabFORGE helped
Neha photographed the red-stamp discharge paper, her father's RGHS card, the three discharge summaries from October, January, and April, and the SMS from the hospital asking if a fourth admission was pre-authorized.
- 🔍 Found the chronic-case exemption. Read RGHS's case-review protocol and discovered: recurring chronic-disease admissions (diabetes, hypertension, kidney disease with multiple episodes) have a "continuous-care pathway" that bypasses pre-approval requirements if the medical condition meets criteria—defined as same diagnosis, same physician, same hospital, multiple admissions within 12 months.
- 💬 Named the exact documents needed. All three discharge summaries (showing same diagnosis, diabetic foot ulcer, Dr. Mehta at SMS Hospital each time), RGHS card, and a request letter to the RGHS Central Review Office invoking "chronic-case continuous-care pathway." The request letter must reference the specific diagnosis code (ICD-10 E11.65 for Type 2 diabetes with foot ulcer).
- 📞 Provided the RGHS Central Review Office email and the specific form name. RGHS-CRO-REQUEST-FM-07 (Chronic Case Exemption Request). Submit by email to [email protected].
Neha submitted the request with all three discharge summaries on April 27. RGHS approved the chronic-case pathway on May 3. When her father's ulcer showed infection signs again on May 15, SMS Hospital admitted him without pre-approval. Full coverage.
🇮🇳 Why this matters
Chronic diseases require repeated care. Fixed audit thresholds treat repeated admissions as suspicious. Exemption pathways exist for chronic cases—they're just not visible in discharge papers or helpline scripts. A daughter has to discover them by reading dense policy manuals.
The long version has the three admissions, the red-stamp audit hold, the pre-approval queue with no timeline, the chronic-case pathway buried in RGHS protocols, and the moment Neha understood the system had an off-ramp—she just needed to know the right phrase to ask for.