The large-scale of Ayushman Bharat Pradhan Mantri Jan Arogya Yojana has grabbed the attention of every private hospital in India. It covers approximately 500 million people to the amount of Rs. 5 lacs per household, which is so big a number for any hospital that they can’t ignore the huge potential of revenue source. Yet, there are doubts, as there has been bad experience by private hospitals in various public health financing schemes, RSBY, the predecessor scheme, for example, is filled with numerous cases where hospitals have not received their payments for a long time even up to years. Although many hospitals get empanelled with the PMJAY, many more are adopting an approach of wait and watch. Should Private Hospitals Empanel For Ayushman Bharat?
Based on a critical evaluation of the scheme and the experience, here are the answers to some of the questions that matter for any private hospital to evaluate whether or not to participate in this scheme. Should Private Hospitals Empanel For Ayushman Bharat?
1. Rates of PMJAY are, adequate or not? Should Private Hospitals Empanel For Ayushman Bharat?
There are fixed tariffs for each of the 1350 treatment packages defined under the scheme. The rates of the scheme are usually similar to CGHS rates. Whether the rates are adequate or not depends upon the category of hospital and their operating cost. While maximum low operational cost hospitals are satisfied with the rates, the high operational cost hospitals find it very low to recover the cost. However, for many hospitals, the high volume of patients that the PMJAY brings compensates the lower rates to some extent through the price-volume effect on revenue.
2. How many patients can the hospital expect through the scheme? Should Private Hospitals Empanel For Ayushman Bharat?
PMJAY will cover almost 50% of the population of India, there is no other scheme that can even remotely match the number of patients that the scheme can give. The scheme has the potential to give more patients than all private hospitals combined can serve. Smaller hospitals in tier 3 & tier 4 cities are in fact already generating up to 70% of their revenue from PMJAY patients. The awareness campaign has been organized very well in many states. During the initial months of the scheme launch, a letter from the PM was sent by post to all beneficiary families informing them about the PMJAY. Many states have organized awareness campaigns for the scheme. However, the number of beneficiaries who actually received their golden cards is still very low, which indicates that it will take some more time for the PMJAY to operate at its full potential. Should Private Hospitals Empanel For Ayushman Bharat?
Also Read:- Why NABH Is Important For Your Hospital
3. What is an incentive for NABH Accreditation/Certification or for good quality hospitals? Should Private Hospitals Empanel For Ayushman Bharat?
The PMJAY is promoting good quality hospitals by paying a percentage increase to the rate. As of now, NABH Accreditation/Certification is the only criteria that the scheme uses for recognizing a good quality hospital. A hospital with full NABH accreditation is paid 15% more while those with only pre-accreditation status are paid 10% higher than the base package rates. Other than NABH, there is also an option of the hospital to acquire a ‘Bronze certificate’, under the Quality Certification System of PMJAY (in collaboration with QCI). Bronze certificate hospitals are entitled to receive a 5% increase over the base package rates. Should Private Hospitals Empanel For Ayushman Bharat?
4. In how much time the hospital will get the payment of the claim amount? Should Private Hospitals Empanel For Ayushman Bharat?
There is a fixed turn-around time of 15 days (30 days in some states) for payment of claims submitted by the hospital. If the payment is not done on time, a penalty of 1% of the claim amount per week of delay is to be paid to the hospital. Defined TAT and penalty clause provide some assurance to the private hospitals about timely payment. Experience of empanelled hospitals till now with the claim settlement time has been satisfactory.
Also Read:- The Process of TPA Empanelment for Hospitals in India
5. Will they reject claims for non-serious reasons? Should Private Hospitals Empanel For Ayushman Bharat?
There are checks and balances in the scheme to ensure that legitimate claims are not rejected. The claims usually go to a TPA for verification. The process of verification and evidence to be checked has been well-defined for each treatment package and is available in the public domain. If there are issues in verification, the hospital is given the opportunity to explain or give further proof, before rejecting the claim. Each claim rejected by the TPA is re-checked by the Insurance Company or the state health agency for confirmation. Also, there is an option of appeal by the hospital for a rejected claim, through which the rejected claim can be re-investigated. Should Private Hospitals Empanel For Ayushman Bharat?
6. How smooth is the entire process of empanelment and claim management? Should Private Hospitals Empanel For Ayushman Bharat?
The scheme is executed through an online IT-based system, which has made it efficient. Everything, right from applying for empanelment to submission of claim, replying to queries from TPA etc. online. This has made the process faster, transparent and easier for all the involved stakeholders. However, from state to state there is a variation in ease of execution.
7. Are other hospitals getting empanelment? Should Private Hospitals Empanel For Ayushman Bharat?
Under the scheme, private hospital empanelment is done by a process taking a maximum of one month time. The number of private hospitals getting empanelled with the PMJAY is continuously increasing. More than 14,000 private hospitals have empanelled so far and many more are in the process of empanelment. The number of patients taking treatment in these hospitals and the total amounts being claimed is continuously increasing. In many cities and towns, there are adequate hospitals empanelled so a hospital that is not empanelled is losing patients & revenue.
8. What are the precautions that a hospital should take? Should Private Hospitals Empanel For Ayushman Bharat?
a. The hospital applying for empanelment should apply for all the specialities that they provide and cannot choose certain specialities for empanelment. However, the state has the right to reject some or all of its specialities for empanelment if the required criteria are not fulfilled. Should Private Hospitals Empanel For Ayushman Bharat?
b. Once empanelled, the hospital can’t refuse treatment to any PMJAY beneficiary patient who reaches the hospital for services, except in certain conditions such as no beds available.
c. There are certain rules that the empanelled hospital must follow. For example, no cash should be taken from PMJAY patients, hiring and maintaining a dedicated staff called Ayushman Mitra, Refunding the OPD payment taken from the patient, in case the beneficiary was admitted and treated etc. Non-compliance to rules can lead to various grades of penalty. Should Private Hospitals Empanel For Ayushman Bharat?
Overall, the scheme is good for those hospitals that operate at low-to-moderate operational costs. The challenge of non-payment, delayed payment, complex processes etc. has been well addressed. High-class hospitals, with higher operational costs, however, should examine the rates carefully before considering empanelment. They can plan to reduce their operational cost for bulk patients. Should Private Hospitals Empanel For Ayushman Bharat?
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