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NHA, IRDA release reports focussing on transformation of Indian health insurance ecosystem

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The reports are result of four sub-groups formed to work in-depth with diligence, focus on each area

National Health Authority (NHA) and Insurance Regulatory and Development Authority of India (IRDAI) recently launched ‘four’ reports focussing on – Hospital Network Management, Common IT Infrastructure for Health Insurance Claims Management, Fraud and Abuse Control and on Data Standards and Exchange. The report was launched by Subhash Khuntia, Chairman, IRDAI and Dr Indu Bhushan, CEO, National Health Authority.

A Joint Working Group of IRDAI and NHA was formed to work on key areas of mutual interest and co-operation. The reports are a result of four sub-groups formed to work in-depth with diligence and focus on each area. These groups focussed their work on four key areas:

1. Hospital network management: To build a National Repository of Empanelled Hospitals under insurance/Government schemes with defined standards for quality and package rates and codes by:

a) Defining hospital infrastructure and facility audits to understand the capacity of hospitals and the availability of specialists
b) Developing a roadmap to get one common list of accredited verified hospitals for the entire industry including ROHINl, NHRR, NIN and PMJAY databases
c) Comparative study of packages, their rates and mapping to uniform codes
d) Defining standards and indicators for safe and quality healthcare to patients

2. Data standardisation and exchange: To create standard data formats across health insurance payers for analysis and policy-making by:

a) Developing standardised data tables to capture and report the data, identifying data elements common with IRDAI and PMJAY
b) Setting up a framework for capturing and exchanging data

3. Fraud and abuse control: To help detect and deter frauds through common repository and capacity building by:

a) Developing a standard reporting format for fraud and abuse to be used across the industry and Govt schemes
b) Making a repository of fraudulent transactions, modus operandi and entities
c) Develop standards for field verification and investigation
d) Develop the ‘name and shame’ guidelines

4. Common IT infrastructure for health insurance claims management: To increase service efficiency and transparency amongst stakeholders in the delivery of health insurance services by:

a) Defining the roadmap for electronic, paperless, codified data exchange between payer and provider, collation and analysis
b) Defining a roadmap for the creation of standard electronic personal health record for the insured population with a common identifier

60 per cent 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 ecosystem in the country, making it more efficient and effective.

Dr Bhushan also expressed great satisfaction at work done by JWG and 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.”

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

The recommendations in the report include best practices, common standards, collaborative measures and IT framework, will benefit all stakeholders – beneficiaries, policyholders, insurers, state health agencies, healthcare providers, implementing agencies and intermediaries etc. The reports of Joint Working Group shall be available on IRDAI and NHA website for comments by industry and public at large.

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