In a joint report released on Saturday by the National Health Authority (NHA) and the Insurance Regulatory and Development Authority of India (IRDAI), has recommended best practices, common standards, IT framework and collaborative measures for effective healthcare through health insurance across India.

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According to the report, robust arrangements will benefit all stakeholders including beneficiaries, policyholders, state health agencies, healthcare providers, implementing agencies and intermediaries, etc.

“These reports would help further strengthen the transparency, efficiency, and effectiveness of PMJAY, benefitting millions in India directly," said Indu Bhushan, CEO, National Health Authority.

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The Reports by the Joint Working Group focuses on Hospital Network Management, Common IT Infrastructure for Health Insurance Claims Management, Fraud & Abuse Control and on Data Standards & Exchange.

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Good standards for quality

Building a National Repository of Empanelled Hospitals under insurance/government schemes with good standards for quality and package rates have been recommended by the report. The following can be achieved by defining hospital infrastructure and facility audits to understand the capacity of hospitals and the availability of specialists.

“The implementation of these recommendations shall create a positive impact and lead to further growth of health insurance in the country," said Subhash Khuntia, Chairman, IRDAI.

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Scheme to detect and eliminate fraud

The scheme is already functioning on detecting and eliminating frauds through common repository and capacity building, the reports have recommended developing a standard reporting format for fraud and abuse to be used across the industry and Government schemes.

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Making a repository of fraudulent transactions, modus operandi and entities, developing standards for field verification and investigation and developing the "name and shame" guidelines can help in the goal.

“Increasing service efficiency and transparency amongst stakeholders in the delivery of Health insurance services can be done by defining the roadmap for electronic, paperless, codified data exchange between payer and provider, collation and analysis," said the report

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