IRDAI, NHA suggest measures to ensure effective healthcare by insurance

The IRDAI and National Health Authority have recently launched a collaborative report suggesting best practices, common standards, collaborative measures and IT framework for data standardisation and to check frauds. IRDAI and NHA has formed a joint working group in order to work on key areas of mutual interest and co-operation that focus on their work on four crucial areas, such as, Hospital Network Management, Data Standardization and exchange, Common IT infrastructure for health insurance claims management and Fraud and abuse control. The experts in the report on Hospital Network Management, has recommended building a national repository of empanelled hospitals under insurance/government schemes with defined standards for quality and package rates and codes. Meanwhile, the report on Data Standardization and Exchange emphasizes on the creation of standard data formats all over health insurance payers for analysis and policy-making by developing standardised data tables to capture and report the data, identifying data elements common with IRDAI and PMJAY. The suggestive measures also included setting up a framework for capturing and exchanging data. The report on Fraud Control sheds light on in detecting and deterring frauds through common repository and capacity building by developing a standard reporting format for fraud and abuse to be used across the industry and government schemes. The report also suggests of creation of a repository of fraudulent transactions, modus operandi and entities and develops standards for field verification and investigation and developing the “name and shame” guidelines. The report on the Common IT Infrastructure for Health Insurance Claims Management throws light on increasing service efficiency and transparency amongst stakeholders in the delivery of Health insurance services by defining the roadmap for electronic, paperless, codified data exchange between payer and provider, collation and analysis.