Good, Replicable Practices and Innovations under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) – (MJPJAY) as a Key Stakeholder

Mahatma Jyotiba Phule Jan Arogya Yojana (MJPJAY) was launched on 02.07.2012. Earlier only 85% population was covered but under the universal scheme: As per GR dated 23.05.2020 now the entire 100% state population is covered under MJPJAY. The Insurance cover per family per annum is 1.5 lakhs (2.5 lakhs for renal transplant)for MJPJAY & 5 lakhs for PMJAY.

Network of Hospitals

Total empanelled NWHs: 967 (287 Public & 680 private)
Minimum 2 NWHs are being empanelled per taluka
A (100%), B (90%) & C (80%) grades for multispecialty and A (100%) & B (90%) grades for single specialty
‘A’ grade with 100% rate allotted to all the Public Hospitals
Hospitals in neighboring states are being empanelled
One grade higher to the hospitals in tribal, hilly and aspirational districts (Osmanabad, Gadchiroli, Nandurbar & Washim)
Number of beds required for empanelment brought down from 30 to 20 beds for hospitals in tribal, hilly and aspirational districts

Best practices and innovations

100% packages are preauth based
Around 98% Preauths & Claims are processed within stipulated TAT of 12 hours and 15 working days respectively
Rs.63.78 crore unspent IEC amount was recovered from insurance company in June 2018
Premium rate per family per annum was brought down from Rs.690 to Rs.640 in Feb.2019
Appointed Super Specialists & Specialists to review the cases to prevent the fraud and abuse of the packages
Clinical Protocols for evidence based treatment/package selection
Evidence based adjudication guidelines and mandatory investigations – for preuth and claims processing
Follow-up Medicines to eligible beneficiaries till 1 year
2 Tier monitoring System
Arogyamitras deployed by TPAs in each NWH to assist the beneficiaries
Health Camps to create awareness about the scheme
Chairmanship of Central claims committee, Empanelment Committee & Preauth technical committee is with SHAS
Regular visits to NWHs by CEO, SHAS and other officials from SHAS, Insurance Company & TPAs
Biometric attendance System for monitoring of the field & PO team
Periodic rotation of Arogyamitra from hospitals to hospitals
Periodic rotations of SHAS field officers
Stringent fraud deterrence process.
Social Audit Mechanism- Beneficiary Feedback Mechanism
Pre-recorded voice message of Hon.Chief Minister
SMSes are sent to all beneficiaries in local language at various stages during the hospitals stay
Dynamic Grading of the Hospitals- Package rates linked to Grade so as to maintain the quality
24X7 dedicated Call Centre with 32 lines monitored by SHAS & 24X7 Grievance redressal system
Hosting web services on Cloud Environment
Re-appeal system for claims rejection & deduction
Refund of excess premium from Insurance Company, if ICR is blow 85%
3 separate open e tenders were floated: Insurance Company, Call centre & IT Company

Transparency In Processes

24X7 Online Preauthorization & Claims Settlements
Emergency Telephonic Intimation Service – For emergency Treatment (Accidental treatment, CVTS, Cardiology Treatment)
Technical Committee to review rejected preauths
Repudiation & Central Claim Monitoring System (Amount approved in CCM is around Rs.16 crore)
Online Empanelment Process Coordination Empanelment Disciplinary Committee

COVID 19 Care

Total 20 packages under Pulmonology, Critical care, Nephrology & Pediatric Medical Management
Till date 3378 COVID positive patients have availed benefit under the integrated scheme
Charges of private hospitals restricted as per the notification dated 21.05.2020 (80% regulated beds and 20% non-regulated beds)
CEO, SHAS is monitoring authority in the state for the implementation of the notification dated 21.05.2020
In response to the notification dated 21.05.2020 till date 65 grievances have been received and resolved. Due to intervention of SHAS till date Rs.13,37,578 waived off from the bill amount/ reimbursed back to the patient’s family
Committee chaired by CEO, SHAS finalized the COVID 19 test cost : Cost brought down to Rs.2200 from Rs.4500
Emergency Telephonic Intimation (ETI) provided to maximum cases in the light of lockdown amidst COVID 19 pandemic
In ETI cases limit of 5 working days extended up to 70 days for submission of documents
Photo copies of ration card & photo ID and https://nexusofgood.org.in/wp-content/uploads/2020/11 received on WhatsApp are also accepted
Ration card generated through website of the website of Food & Civil Supplies department is also considered
Around 500 additional hospitals empanelled in the first week of April 2020
210+ COVID hospitals
Free COVID test in empanelled hospitals under scheme packages
Government to acquire private ambulances/ vehicles and fix transport charges for such acquired ambulances for citizens

Updates as on 23.05.2020

Universal scheme: MJPJAY scheme benefits extended to the families who don’t have any ration card
Families who don’t hold any ration card can avail benefit on the basis of domicile certificate/Tehsildar certificate along with valid photo ID
CEO, SHAS has an authority to relax the documents required for availing the scheme benefits
120 Government reserved procedures opened for private hospitals
Additional 67 diagnostic, minor & major procedures for private hospitals (includes procedures like Delivery, Caesarian section, ECG, X ray, 2D Echo, Endoscopy, USG etc.)