Health Insurance Board Orders Hospitals to Stop Unnecessary Patient Referrals

Nepal’s Health Insurance Board has instructed all insurance-affiliated health institutions to immediately halt the practice of referring patients unnecessarily to other facilities.

In a notice issued on Thursday, the Board stated that several hospitals have been referring insured patients elsewhere despite having the required services available in their own facilities. Such practices, the Board said, place avoidable financial and logistical burdens on patients and undermine the intent of the national health insurance system.

The Board clarified that referrals made while ignoring available in-house services violate the Health Insurance Act 2017, the Health Insurance Regulation 2018, and the Referral Procedure 2023. Health institutions have been formally warned not to continue such actions.

Where a service genuinely cannot be provided, the Board has directed hospitals to follow the referral process outlined in Schedule 9 of the Health Insurance Regulation 2018, ensuring patients are sent to the nearest appropriate facility with proper documentation.

The Board has further warned that institutions found breaching these directives will face strict consequences. Claims linked to unnecessary referrals will not be reimbursed, and violators risk suspension or cancellation of their insurance contracts under Schedule 8, Clause 4(c) of the regulation.

The directive signals a tighter enforcement phase as the Board moves to protect patient rights and control systemic misuse within the insurance network.