NHA, IRDAI Recommend Measures To Check Frauds, Data Standardisation 

The National Health Authority, responsible for implementing the Ayushman Bharat scheme, and Insurance Regulatory and Development Authority of India have launched a report recommending best practices, common standards, collaborative measures and IT framework for data standardisation and to check frauds.

A joint working group of the insurance regulator and NHA was formed to work on key areas of mutual interest and cooperation which focussed their work on four key areas—hospital network management, data standardisation and exchange, common IT infrastructure for health insurance claims management and fraud and abuse control.

In the report on hospital network management, the experts recommended building a national repository of empanelled hospitals under insurance/government schemes with defined standards for quality and package rates and codes.

The report on data standardisation and exchange stresses on creating standard data formats across health insurance payers for analysis and policy-making by developing standardised data tables to capture and report the data, identifying data elements common with IRDAI and PMJAY.

It also includes setting up a framework for capturing and exchanging data.

The report on fraud control focuses to help detect and deter frauds through common repository and capacity building by developing a standard reporting format for fraud and abuse to be used across the industry and government schemes.

It also recommends creating a repository of fraudulent transactions, modus operandi and entities and develop standards for field verification and investigation and developing the “name and shame” guidelines.

The report on the common IT infrastructure for health insurance claims management focuses on increasing service efficiency and transparency among stakeholders in the delivery of health insurance services by defining the roadmap for electronic, paperless, codified data exchange between payer and provider, collation and analysis.

Sixty percent of the Indian population today is covered under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana and privately paid health insurance making it a great opportunity for IRDAI and NHA to jointly work on key areas for the strengthening of health insurance eco-system in the country, making it more efficient and effective, an NHA official said.

“The recommendations in the report are a step forward in enabling quality healthcare and access to the patients. These reports would help further strengthen the transparency, efficiency and effectiveness of AB-PM-JAY, benefiting millions in India directly,” Indu Bhushan, chief executive officer of NHA.

The completion of these report in record time is a huge achievement, and I thank the members of the Joint Working Group who have toiled to put them together, Subhash Khuntia, chairman of IRDAI, said. We are confident that implementation of these recommendations shall create a positive impact and lead to further growth of health insurance in the country, he said.

The recommendations will benefit all stakeholders beneficiaries, policyholders, insurers, state health agencies, healthcare providers, implementing agencies and intermediaries etc, officials said.

The reports of the joint working group shall be available on IRDAI and NHA websites for comments by industry and public.