Surgeons, medial staff and observers gather around a patient during an operation inside theater at Queen Elizabeth Hospital Birmingham. (Photographer: Matthew Lloyd/Bloomberg)

IRDAI Partners With National Health Authority To Study Ayushman Bharat

The Indian insurance regulator said that it has partnered with the National Health Authority to study the prime minister’s health insurance scheme and suggest measures to streamline its implementation.

The agencies will form a joint working group, which will set up a national repository of hospitals with uniform standards for quality, package rates and codes within a year, according to a notice on the Insurance Regulatory and Development Authority of India’s website. It will examine aspects such as package rates offered to hospitals, fraud and abuse control and a common IT infrastructure for claims management. “The group will come up with a methodology for revision of existing rates offered for different procedures under the scheme,” said Indu Bhushan, chief executive officer at NHA.

The working group will be chaired by Dinesh Arora, deputy chief executive officer at NHA, and co-chaired by Suresh Mathur, executive director (health and insurance marketing firms) at IRDAI, and will comprise nine other members.

The Pradhan Mantri Jan Arogya Yojana, popularly known as Ayushman Bharat, looks to provide cashless hospitalisation for 1,354 procedures to 10 crore poor families for Rs 5 lakh per family per year. In the five months since its launch, the scheme provided cashless treatment worth Rs 1,911.8 crore to 14.4 lakh beneficiaries. There are about 14,789 empanelled hospitals within the scheme, of which more than half are private hospitals.

The department of health research, under the Ministry of Health & Family Welfare, has formed 24 technical committees to study rates for 250 of the most utilised procedures. The study is based on a comparison of rates offered under government health insurance schemes and private hospitals, Bhushan said.

Even as the government increased its budget to Rs 6,400 crore for the financial year 2019-20 from Rs 2,000 crore in the previous fiscal, package rates offered under the scheme were unchanged. That worried private hospitals, which had earlier threatened to stay away from the scheme, citing unviable and unscientific pricing.

“The prices for some of the most utilised procedures, mainly in the cardiology and oncology specialties, may start getting rationalised by July, based on the first report submitted by the department of health research,” said Dinesh Arora of NHA. The suggested rates, Arora said, may be extrapolated with other packages or the working group may present a separate methodology to the NHA within a year. “It’s still a work in progress.”

The committee will also develop standard formats for reporting of fraud and a repository of fraudulent transactions within six months, along with a roadmap for creation of standard electronic personal health records for insured population. The group will have its first meeting on March 12, said Arora.

“IRDAI has already developed a database of network hospitals used by the insurers and this can be expanded to an exhaustive list of all hospitals used under PMJAY,” said Subhash Chandra Khuntia, chairman at IRDAI. The regulator will assist NHA in developing a framework for risk management, pricing, claims management and data analytics, which will be of help in administering the scheme more efficiently and effectively in case of both insurance and trust models, he said.