Government of India has launchedAyushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) for providingsecondary and tertiary care cashless treatment at empanelled private and publichospitals across the country to families listed in SECC (Socio-Economic CasteCensus) 2011.To support the Implementation of AB-PMJAYwith the active involvement of various stakeholders and to further strengthenthe health insurance ecosystem it is desired that IRDAI and NHA work on key areas of mutual interest andcooperation.

In order to work inthis direction, a Joint Working Group is constituted with the followingMembers:

1.      Dr Dinesh Arora, Dy.CEO,NHA , Chair

2.      Mr. Suresh Mathur,ED, IRDAI, Co- Chair

3.      Mr.Kunnel Prem, CEO, IIB, Member

4.      Ms.YegnapriyaBharath, CGM, IRDAI, Member

5.      Mr. A.V. Rao , G M,IRDAI, Member

6.      Mr. D V S Ramesh, GM, IRDAI, Member

7.      Dr Arun Gupta , ED,NHA,Member

8.      Mr. KiranAnanndampillai, Advisor, NHA, Member

9.      Mr. Nishant Jain, Advisor,NHA, Member

10.   Ms. Malti Jaswal, Advisor,NHA, Member

11.   Dr Pankaj Sharma , Manager,IRDAI , Member-Convener

Terms of reference for the Joint Working Group shall be: -

1.    Networkhospitals management: To have a National Repository of EmpanelledHospitals under Insurance/Government schemes with defined standards for qualityand package rates and codes.

                         i.    DefiningHospital infrastructure and Facility Audits to understand capacity ofHospitals, Specialists availability.

                        ii.    Developing aroadmap to get one Common list of Accredited/ Verified hospitals for the entireIndustry including ROHINI, NHRR, NIN and PMJAY Databases.

                       iii.    ComparativeStudy of Packages and their rates and mapping to uniform codes.

                       iv.    DefiningStandards and Indicators for safe and quality Healthcare to Patients.

Timeline: 12 months

2.   Data Standardization and exchange: Tocreate standard data formats across Health Insurance payers for analysis andpolicy making.

                         i.    Developingstandardized data tables to capture and report the data, identifying dataelements common with IRDAI and PMJAY.

                        ii.    Setting up aframework for capturing and exchanging data.

Timeline: 3 months

3.   Fraud and abuse control: To help detect and deterfrauds through common repository and capacity building.

                         i.    To develop astandard reporting format for fraud and abuse to be used across the industryand Govt. Schemes.

                        ii.    Repository offraudulent transactions, modus operandi and entities.

                       iii.    Develop standardsfor field verification and investigation.

                       iv.    Develop “nameand shame” guidelines.

Timeline: 6 months

4.    CommonIT infrastructure for health Insurance claims management: ToIncrease service efficiency and transparency amongst stakeholders in deliveryof Health Insurance services.

                         i.    Defining theroadmap for electronic, paperless, codified data exchange between payer andprovider, collation and analysis

                        ii.    Defining aroadmap for creation of standard electronic personal health record for insured populationwith a common identifier.

Timeline: 6 months

The working group may hold meetings asand when needed and submit a report with recommendations within the timelines prescribed.The working group may consultexperts from the Insurance Industry, Healthcare Providers, NABH, IT, Third PartyAdministrators etc. in the course of their deliberations..  

Sujay Banarji

Member