The report stated that such a robust arrangement will benefit all stakeholders – beneficiaries, policyholders, insurers, state health agencies, healthcare providers, implementing agencies and intermediaries etc.
The Reports of Joint Working Group focus on — Hospital Network Management, Common IT Infrastructure for Health Insurance Claims Management, Fraud & Abuse Control and on Data Standards & Exchange.
The reports have recommended to build a National Repository of Empanelled Hospitals under insurance/Government schemes with defined standards for quality and package rates and codes. The report said that it can be achieved by defining hospital infrastructure and facility audits to understand the capacity of hospitals and the availability of specialists.
The report has also recommended developing a roadmap to get one common list of accredited verified hospitals for the entire industry including ROHINl, NHRR, NIN and PMJAY databases.
Further recommendations include comparative study of packages, their rates and mapping to uniform codes and defining Standards and indicators for safe and quality Healthcare to Patients.
The reports have highlighted that to create standard data formats across Health insurance players for analysis and policy-making can be done by developing standardised data tables to capture and report the data, identifying data elements common with IRDAI and Ayushman Bharat—Pradhan Mantri Jan Arogya Yojana (AB- PMJAY) and up a framework for capturing and exchanging data.
The PMJAY, also dubbed Modicare, which is billed as the world’s largest health assurance scheme, aims to provide free health insurance of ₹5 lakh per family to nearly 40% of the population—more than 100 million poor and vulnerable families—based on the Socio Economic Caste Census. The premium payment expenditure is shared by the central and state governments.
“These reports would help further strengthen the transparency, efficiency and effectiveness of AB-PM-JAY, benefitting millions in India directly," said Indu Bhushan, CEO, National Health Authority.
As the scheme is already working on detecting and deterring frauds through common repository and capacity building, the reports have recommended developing a standard reporting format for fraud and abuse to be used across the industry and Govt. Schemes.
The reports have said that making a repository of fraudulent transactions, modus operandi and entities, developing standards for field verification and investigation and developing the "name and shame" guidelines can help in the goal.
“Increasing service efficiency and transparency amongst stakeholders in the delivery of Health insurance services can be done by defining the roadmap for electronic, paperless, codified data exchange between payer and provider, collation and analysis," said the report.
“Defining a roadmap for the creation of standard electronic personal health record for the insured population with a common identifier, can also help in checking frauds," it said.
“The implementation of these recommendations shall create a positive impact and lead to further growth of health insurance in the country," Subhash Khuntia, Chairman IRDAI said.