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

Started in 2002, Vidal Health has become an integrated healthcare services player catering to the entire healthcare value chain capable of addressing of healthcare markets across the globe, We are among the leading providers of Third Party Administration (TPA) Services with our strong medical expertise, existing state of art technology for risk assessment and administration; provide outstanding customer service by delivering an end-to-end solution for Claims Administration & other business features for our customers and end users
 
Health being a state subject, different states had different arrangements for healthcare delivery for the needy unaffordable population, till a common system through AB PMJAY was introduced in 2018.
 
AB PMJAY provided the broad governing principles and framework, with states free to choose their implementation models, necessitating mutual analysis and exchange of best practices through the now available common platform called NHA to provide the best possible benefit to the beneficiaries.
Backed by long term experience in running various State Schemes, the best practices of different states under the aegis of AB PMJAY have been brought together to aid in improvisation of practices and replication wherever necessary.
 
Preauth & Claim processing forms the core of any Scheme, with best practices such as strict adherence to established protocols, preventing experimental treatments, double check of qualifications of Doctors certifying the investigation reports and administering treatment, mandatory procedure videos for interventions such as PTCA, Clinical Photos with Insurance Coordinators to prevent fraudulence in cyclical cases such as Dialysis, calling all patients to ensure the genuineness of their symptoms/treatment.
 
The success of any mass Scheme lies in accessible, efficient, quick and humane Grievance redressal mechanism. For instance, the Monday 3pm Grievance meet of Tamil Nadu Scheme is widely acclaimed, this is supplemented by monthly Hospital Nodal Officers’ Meets, Need More Info meets to clear pending queries.
 
Audit & Abuse Control mechanism plays a major role in preventing fraud and ensures that only genuine claims are paid for. Inputs from varied sources such as Inbuilt Triggers in the portal, Preauth & Claim Processing teams, Field audit teams, concurrent & post claim audit, interaction of Insurance Coordinators with patients, verification till the last detail such as Hospital Pharmacy stock registers, hospital infrastructure audits Viz Dialysis Unit, Cath Lab, attendance registers etc supplemented by periodic evaluation and training aid in payment of genuine Claims and corrective action against erring hospitals.
 
A Hospital grading system (in addition to NABH accreditation) based on available infrastructure with corresponding package rates and payments, motivates hospitals to climb up the Grading ladder and upgrade their infrastructure to provide better services to beneficiaries in the long term. Advanced treatment packages such as PTCA, CABG, TKR, THR, Transplants etc. may be enabled only after the hospital provides evidence of positive outcomes. 
 
Serving wide geographical areas wherein natural calamities are common, Crisis preparedness and provision of seamless services during natural disasters achieves the objective of best service irrespective of the nature of crisis. Continuation of services in coordination with beneficiaries, Hospitals and Government authorities was witnessed most recently in the current Covid 19 pandemic wherein patients requiring cyclical treatment Viz Dialysis, Chemotherapy, Radiotherapy etc. haven’t missed their treatment schedules and thousands of Health Camps were coordinated.
 
Knowledge is a treasure but yields fruits only on practice. Innovation and strategizing is done on a continuous basis, churning out Best practices to tackle state specific challenges. With our long-term experience in handling different state Schemes and Schemes abroad, we cross pollinate the best practices across various states for best outcomes, ensuring the best of health to all eligible beneficiaries.
 
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