Technology will help Ayushman Bharat overcome the initial challenges
By Ritesh Kajaria
An integrated artificial intelligence-based system can iron out the loopholes that lead to fraud claims
Just over a year ago, on September 23, 2018, India started Pradhan Mantri Jan Arogya Yojana (PM-JAY) or Ayushman Bharat, one of the most ambitious comprehensive cashless health insurance schemes in the world. The vision of this initiative is to create a ‘Healthy India’. Looking at the initial results, the scheme has done well in terms of reaching the hinterlands and providing affordable healthcare services. According to the National Health Authority (NHA), the agency responsible for implementation of the scheme, about 46.4 lakh less privileged Indians have received treatment worth Rs 7,500 crore through hospitalization under the scheme. While, there is no difference of opinion about the purpose and impact of Ayushman Bharat, the journey so far has thrown up multiple challenges on-ground, majorly due to documentation issues.
One such challenge is to strengthen its fraud control mechanisms. The scheme offers an average annual health insurance cover of Rs 5 lakh per family. Going by the past year’s data, the average cost of treatment per patient is about Rs 16, 164. Given that all the family members may not need treatment in the same year, a higher cover opens a big opportunity for fraud. Often, this is done by forging a relationship with the head of the beneficiary family basis fake documentation, fake medical history, or erroneous billing. NHA has accepted that there is no way to eliminate such fraud.
However, focus on technology can address a large part of this problem. For instance, a connected repository of digital healthcare records will allow the ecosystem, i.e., hospitals, TPA, and state authorities a full rundown on any claim. Based big data analytics, artificial intelligence, and machine learning, the system can automatically sift through the claim forms, medical history of the patient, and state records to identify any discrepancies. For instance, if an individual has no alarming cardiac test history over the past six months, and there is a sudden claim filing, there could be a need for manual investigation. The analysis of other lab reports over a period could also be helpful in pre-empting any fraud claims. Similarly, by connecting the social security details such as AADHAR, chances of forging a fake relationship could be minimized. At the core of every step is identifying the right data points, mine the data over a long period, compare trends, and validate every claim.
Technology driven automation also helps in minimizing the human resource requirements for validating the claims. Hence, the cost for processing every claim can come down as much as to Rs 15-20 from Rs 500 approximately as of now. This has a ripple effect on the premium costs and the exchequer may save about 20 percent on it. At the same time, the turnaround time between raising a claim and the final settlement reduces, making it a win-win situation for everyone.
Given the dire shortage of hospitals, last mile connectivity, and other challenges, penal measures such as banning fraudulent institutions is not an option for NHA. The need of the hour is to implement fully integrated and automated platform for managing the claims under Ayushman Bharat. Manual intervention should be minimized and used only if it is required. As technology brings the initial change, there will be higher appetite to upgrade the systems for higher efficiency, effectiveness and accuracy. This will also help in building higher level of trust among all players in the ecosystem and pave way towards making India a truly healthy, prosperous and developed nation.
Author: Ritesh Kajaria, Founder & CEO, Healthnine