The massive scale of Ayushman
Bharat – Pradhan Mantri Jan Arogya Yojana has caught the attention of every private
hospital in India. Covering almost 500 million people to the extent of Rs. 5
lacs per family, is too big a pool for any hospital to miss. Yet, there are
apprehensions, as there has been bitter experience by private hospitals in various
public health financing scheme. RSBY, the predecessor scheme, for example, is
mired with numerous cases where hospitals have not reveived their payments for many
months or even years. Hence, while many hospitals have empanelled themselves
with the scheme, many more are taking a cautious approach of wait and watch.
Based on the scheme design and
the experience, here are the answers to some of the questions that bothers any
private hospital evaluating whether or not to participate in this scheme.
1. Are
the rates at which hospital services are paid, adequate?
There are fixed rates
for each of the 1350 treatment packages defined under the scheme. The rates are
largely similar to CGHS rates. To give an idea, Haemodialysis is paid at Rs. 1500/- per session, Cholecystectomy at Rs. 22800/-, Caesarean delivery at Rs. 11,500/-
and PTCA with one stent at Rs. 40,600/-. For medical conditions IPD stay is paid
at Rs. 1800/- per day for general ward and Rs. 3,600/- per day in ICU (without
ventilation). Whether the rates are sufficient or not depends upon the class of
hospital and their operating cost. While most low cost hospitals are satisfied
with the rates, the high class hospitals finds it too low to even recover the
cost. However, for many hospitals, high volume of patients that the scheme
brings do offshoot the lower rates to some extent through the price-volume
effect on revenue.
2. How much volume of work can the hospital expect through the scheme?
With provision to
cover almost half the population of India, there is just no other scheme which
can even remotely match the volume of patients that PMJAY can supply. The
scheme has potential to provide more patients than all private hospitals
combined can serve. Smaller hospitals in small towns are in-fact already
generating up-to 70% of their revenue from PMJAY patients. The awareness
campaign has been done very well in many states. During the initial months of
scheme launch, a letter from PM was sent by post to all beneficiary households informing
them about the scheme. Many states have organized events and campaigns to create
awareness. However, number of beneficiaries who actually got their golden cards
made is still very less, which indicates that it will take some more time for
the scheme to operate at full potential.
3. Do
they give any incentive to good quality hospitals?
The scheme is
incentivizing good quality hospitals by paying a percentage premium to the rate.
As of now, NABH accreditation is the only criteria that the scheme uses for recognizing
a good quality hospital. A hospital with full NABH accreditation is paid 15%
higher while those with only pre-accreditation status is paid 10% higher than
the base package rates. Other than NABH, there is also a provision of hospital acquiring 'Bronze certificate', under Quality Certification System of PMJAY (in collaboration with QCI). Bronze certificate hospitals are entitled to receive 5% premium over the base package rates.
4. How
much time do they take to pay the claim amount?
There is a
defined turn-around-time of 15 days (30 days in some states) for payment of
claims submitted by the hospital. If the payment is delayed, a penalty payment
of 1% of the claim amount per week of delay is to be paid to the hospital.
Defined TAT and penalty clause provides some comfort to the private hospital
about timely payment. Experience of empanelled hospitals so far with the claim
settlement time has been satisfactory.
5. Won’t
they reject claims for frivolous reasons?
There are checks
and balances in the system to ensure that legitimate claims are not rejected. The
claims generally go to a TPA for verification. The process of verification and proofs
to be checked, has been well defined for each treatment packages, and is
available in public domain. If there are issues in verification, the hospital
is given opportunity to explain or provide further proofs, before rejecting the
claim. Each claim rejected by the TPA, is re-examined by the Insurance Company
or the state health agency for confirmation. Also, there is a provision of appeal by the
hospital for rejected claim, through which rejected claim can be
re-investigated.
6. How efficient
is the entire process of empanelment and claim management?
The scheme is
operational through an online IT based system, which has made it efficient. Everything,
right from applying for empanelment to submission of claim, answering queries
from TPA etc. are online. This has made the process faster, transparent and easier
for all the involved parties. However, from state to state there is a variation
in ease of operationalization.
7. Are other hospitals getting empanelled?
While all public
hospitals with IPD facility has been deemed empanelled under the scheme,
private hospital empanelment happens through a process which takes maximum one
month time. The number of private hospitals getting empanelled with the scheme
is steadily increasing. More than 12,000 private hospitals have empanelled so
far and many more are in process. The number of beneficiaries taking treatment
in these hospitals and the total amounts being claimed is continuously on rise.
In many cities and towns there are enough hospitals empanelled, so that a
hospital which is not empanelled are losing patients.
8.What
are the cautions that a hospital should be aware of?
a. The hospital applying for empanelment should
empanel for all the specialities that they offer and cannot choose specific
speciality for empanelment. However, the state has the right to reject some or
all of its specialities for empanelment if the required criteria are not met
b. Once empanelled, hospital cannot refuse
treatment to any PMJAY beneficiary patient who access the hospital for
services, except in exigencies such as no beds available.
c. There are certain rules that the empanelled
hospital must adhere to. For example, no cash should be taken from PMJAY
beneficiary, hiring and maintaining a dedicated staff called as Ayushman Mitra,
Refunding the OPD payment taken from beneficiary, in case if the beneficiary was
admitted and treated etc. Non-compliance to rules can lead to various grades of
penalty.
