IRDAI, NHA form joint working group on Ayushman Bharat

In News

• A Joint Working Group has been constituted for better implementation of Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY).

 

News Summary

• The union government has constituted an 11-member Joint Working Group (JWG) constituting members from IRDA and NHA.
• Primary aims
  • To support implementation of Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)
  • To standardize protocols for health insurance services
  • To strengthen the health insurance ecosystem in India

 

In Focus: Joint Working Group for AB-PMJAY

The JWG will make recommendations in the following areas:

1. Network hospitals management

• I. National Repository of Empanelled Hospitals
  • To consolidate different databases of hospitals including ROHINI, NHRR, NIN and PMJAY into a single National Repository of Empanelled Hospitals for insurance schemes.
  • ROHINI: Registry of Hospitals in Network of Insurance is a data registry of hospitals in the health insurer and third-party administrator network in India.
  • NHRR: National Health Resource Repository is basically a census of healthcare establishments, public and private.
  • NIN: National Institute of Nutrition

• Impact
  • Responsive: It will remove deficiencies like non-reporting, under-reporting and delays thereby making the health sector more responsive to citizen health needs.
  • Leveraging Private Health Infrastructure: One national repository will help in leveraging private health infrastructure.
  • Fraudulent Claims Management: Single national repository of empanelled hospitals will reduce fraudulent claims and thus reduce claim costs.

 

• II. Standardized Treatment and Package Rates
  • Need: Currently, the health insurance sector is clogged with following deficiencies:
    • Highly skewed package rates as a result of lack of standardized package rates
    • Subjective decisions for treatments due to lack of defined clinical protocols
    • Lack of standardized hospital infrastructure.
  • Guidelines
    • Around 1,350 treatments including surgical procedures are included for which package rates will be standardised.
    • It will lay out Standarised Treatment Guidelines for safe and quality healthcare.
    • It will define hospital infrastructure to understand capacity of hospitals and in turn help in facility audits.
  • Impact
    • The move will help to curb overcharging thus bringing in uniformity in treatment and hospitalization costs.
    • As a result, it will significantly reduce out-of-pocket expenditure.
    • It will bridge the trust-deficit between patient-health care providers.

 

1. Data Management

• Guidelines
  • JWG will recommend steps for IT-enabled data standardization and exchange in health sector.
  • It will establish standard data formats across health insurance sector.
  • It will also recommend a framework for capturing and exchanging data.
• Impact
  • Linking patient data, hospital data and insurance companies will help in reduction of healthcare cost.
  • Capturing patient data at meta-level will help in disease profiling of population.
  • This will enable policy-makers to make future cost predictions and budgeting for health services.

 

1. Fraud and abuse control

• Guidelines
  • The committee will develop a standard reporting format for fraud and abuse.
  • It will provide a framework for fraud repository.
  • It will develop ‘name and shame’ guidelines for fraudsters
• Impact
  • It will significantly help in detecting fraudulent transaction.
  • It will act as deterrent for fraud.

 

1. Computerization of claims management

• Guidelines
  • JWG will define a roadmap for electronic, paperless, codified data exchange between payer and provider.
  • It will also define a roadmap for creation of standard electronic personal health record of insured population with a common identifier.
• Impact
  • It will help increase service efficiency and transparency in delivery of health insurance services.

 

In Brief: National Health Authority and IRDA

National Health Authority

• National Health Authority is the nodal agency for implementation of AB-PM-JAY.
• It is an attached office under the Ministry of Health & Family Welfare.
• The governing board of NHA is chaired by the Minister of Health & Family Welfare.
• It replaced the existing National health agency to overcome the problem multi-tier decision making and enable speedy and smooth implementation of PM-JAY.
• The CEO of NHA is an officer of the rank of Secretary to the GOI.

IRDA

• Insurance Regulatory and Development Authority is an autonomous body responsible for regulating insurance industry in India.
• It is further entrusted with the responsibility of protecting the interests of the policyholders and increase insurance penetration in the country.
• IRDA is a statutory body set up under the IRDA Act, 1999

 

Earlier related posts:

• In an earlier article, AB-PMJAY was comprehensively covered when the scheme was launched in September 201