india

Updated: Apr 05, 2019 23:16 IST

The government has decided to standardize health insurance across the public and private sectors, seeking to reinforce the medicare system and ensure that claims are settled in no more than 30 days.

The National Health Authority (NHA), the implementing central agency for the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojna (AB-PMJAY), and the Insurance Regulatory and Development Authority of India (IRDAI) are collaborating to develop common claims and information technology systems, codify disease treatment packages and improve overall standards in health insurance.

Hindustan Times has accessed the minutes of the first meeting of the IRDAI and NHA joint working group held last month to discuss network hospital management, data standards and exchange of data sets among agencies, fraud and abuse control, and electronic health exchange information systems for claims.

“Health insurance has been one of the neglected areas and a small piece of the overall insurance sector, what we are aiming at is to make it a substantial part of the insurance sector. We are a new player and are working with IRDAI to have certain standards in place that can be followed uniformly,” said Indu Bhushan, CEO, Ayushman Bharat.

AB-PMJAY, launched in September last year, provides an annual hospitalisation cover of Rs 5 lakh to around 100 million families in at least 16,000 empanelled hospitals. It is billed as the world’s largest public health insurance programme.

Dr Dinesh Arora, deputy CEO, NHA, added, “At the moment, there are information gaps in terms of what diseases are being covered under various insurance schemes, how much is covered, etc. We will prepare a comprehensive report, putting together everything.

“There will be a national benchmark for settling claims in 15-30 days, international coding for each disease, unique ID of each hospital, common standard protocol documentation etc. that will eventually lead to developing gold standards in quality.”

The group will work on defining hospital infrastructure and facility audits to understand the capacity of hospitals and availability of specialists, developing a road map for a common list of verified hospitals across schemes for the entire industry.

As part of the collaboration, comparative studies of packages and their rates will be undertaken and existing data formats of PMJAY will be customised to align them with IRDAI formats.

“The broad idea is to ensure that health insurance schemes work for the benefit of patients and are also sustainable for insurance companies,” said Subhash C Khuntia, chairman, IRDAI.

Fraud and abuse control is one of the key areas that the partnership will focus on. The team will put together a standard reporting format for fraud and abuse to be used across industry and government schemes. There will be a repository of fraudulent transactions, modus operandi and entities, standards for field verification and investigation, and “name and shame” guidelines, among other measures.

The report will be submitted to the NHA CEO within three months and will be the basis for developing a common health insurance system across the country.

Insurance providers welcomed the move.

“There was a need for something like this as it will bring uniformity in the sector. Currently, people are offering various products with several frills attached that can confuse a customer. This standardization is much required,” said Bhaskar Nerurkar, head - health administration team, Bajaj Allianz General Insurance.