Ambala: Amid discrepancy in reimbursement, pilot project on health payments starts

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Ambala, October 7

To strengthen the patient classification and payment systems under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY), health authorities have started a pilot project at Maharishi Markandeshwar Institute of Medical Science and Research in Mullana of Ambala on Friday.

As per the information the pilot project has been launched in five states including Haryana under which diagnostics data will be collected from various private hospitals and submitted to the National Health Authority (NHA). After the data collection the NHA will revise the reimbursement rates to bring more transparency.

Presently hospitals are being reimbursed on per case basis at per day package rate, wherein NABH accredited hospitals or hospitals in metro cities get some percentage of amount more for the same package.

Due to the inefficiencies of the current payment system, hospitals deliberately resort to upcoding.

The hospitals have been requesting that package rates be revised as they were not adequate for many procedures and did not cover even basic cost for providing the treatment, and additional costs for any complications or co-morbidities which may need to be addressed during the treatment, were not covered.

Given the current environment, the use of a case-mix tool that catalogues hospital cases based on similar clinical and cost characteristics would be helpful. The most common case-mix tool called Diagnosis Related Groups (DRGs) which is a system to classify hospital cases into groups, expected to have similar resource use and is assigned mainly on diagnosis and procedure coding, using the International Classification of Diseases, developed by the World Health Organization.

The nodal officer of the Ayushman Bharat Yojana in Ambala, Dr Sukhpreet, said a team comprising Dr Shankar Prinja from the NHA and Dr Monika from State Health Authority, Mullana, had been formed for kicking off the pilot project.