The launch of mass healthcare schemes by the Government has been very fruitful to population of India and has made healthcare affordable and has also helped in standardization of treatment rates
Government of India rolled out RSBY on April 1, 2008, following the same several State Governments set up independent commissions to help achieve universal health coverage for both BPL and APL categories and offering tertiary packages.
September 2018 witnessed the launch of the biggest healthcare scheme in India: PM- JAY more commonly known as Ayushman Bharat. With a plan of covering over 50 crore families and coverage of 5 lakhs per family, an immense amount is involved.
With huge volumes of people getting insured under these schemes and high number of claim pay-outs, concerns over adequate utilization of funds is never behind.
There is a need for systematic implementation support to review the performance and ensure that these schemes have been able to achieve the objectives of better health service utilization, controlling fraud and abuse and better health status.
Apart from that it also becomes essential that the funds are utilized for rational claims and identifying gaps in processes and trends of false payouts becomes essential to contain losses.
What is to be done?
- Mapping of the objectives/ goals
- The protocols covered under the scheme, to be reviewed w.r.t. pre and post documentation mandated & pricing
- Empanelment of hospitals (provider as per SLA)
- Audit of compliance of empanelment and claims processes
- Audit of healthcare delivery by providers and appropriateness of care given
- Audit of preventive care if promised under the scheme
- Blockage/ utilization of packages
- Audit of grievance handling
- basis provider utilization
- basis packages utilization
- basis protocols
- basis enrolled people
- basis location
- Medical audit of every case of death under the scheme
Government has been launching schemes with a final goal of betterment of people and to ensure that the needy can avail healthcare services without any fear of expense. INCHES supports this goal and uses a risk-based approach towards medical audit. With the help of a Tech driven audit/ review/ QC process using an analytical platform, INCHES has been providing 2 level audit services across such schemes.