By Elton Gomes
The Narendra Modi-led government has called on companies to develop an IT framework that can help in identifying alerts for “suspicious” transactions in its PM Jan Arogya Yojana (PMJAY) health insurance scheme, also known as Ayushman Bharat scheme, the Economic Times reported.
What does the government plan to do?
The Centre plans to appoint partners for the project within the next four months after holding extensive consultations, knowledgeable officials said. A total of 14 companies including IBM, L&T Technologies, Lexis-Nexis, IQVIA, and Wipro have shown interest in designing this IT framework, an official familiar with the development told the Economic Times.
The consultations are slated to begin this week, and will reportedly follow directions from the government that the Ayushman Bharat scheme should have “zero tolerance” for fraud.
“Health insurance schemes/programmes are prone to fraud, abuse and leakages, which not only impact the programme financially but also often lead to endangerment of people’s health. Therefore, it is important to prevent, detect and deter fraud effectively through robust processes, trained manpower and timely action backed by state-of-the-art IT systems,” the Centre said in a proposal document, which was reviewed by the Economic Times.
The consultations will be held in order to understand global best practices, policies, procedures, and other IT solutions that can be utilised to build a robust fraud prevention and detection system for the health scheme. After the consultations, the government proposes to invite bids from the companies to provide the service across India.
What is the Ayushman Bharat scheme?
In his Independence Day speech, Prime Minister Narendra Modi announced the initiation of the Ayushman Bharat or National Health Protection Scheme. The scheme is slated to be launched on September 25 – the birth annivarsary of Deen Dayal Upadhyay.
The Ayushman Bharat or National Health Protection Scheme aims to cover more than 10 crore vulnerable families. It also seeks to provide health cover up to Rs 5 lakh per family per year. The programme is being termed as India’s largest health protection scheme.
The scheme is an entitlement and eligibility scheme, and will help only those families on the basis of the SECC (Socio-Economic Caste Census) database.
What other challenges does the Ayushman Bharat face?
Apart from the problems on the technological front, the Ayushman Bharat seems to face other problems as well. An insurance-based model might not be feasible for achieving universal healthcare in India.
Writing for MoneyControl, Dipa Sinha claims in her opinion piece that given the threat of communicable and non-communicable diseases and India’s high burden of out-of-pocket expenditure, inadequate health infrastructure, and a poorly regulated private sector, many would favour a strategy where public expenditure is improved to strengthened the public health system.
Hospitals seem to have another bone to pick over the national health scheme. Hospitals seem unhappy because, according to them, the government’s package rates are loss-making. For instance, the proposed cost of a coronary artery bypass graft is about Rs 90,000 under the Ayushman Bharat scheme. However, the cost of the same surgery under the Central Government Health Scheme (CGHS) in Delhi is above Rs 1.1 lakh, while private hospitals charge above Rs 3 lakh.
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