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As I bump into Gayathri, one of the liaison officers at the Government Kilpauk Medical College, she explains to me that she has just returned after verifying a patient physically – one of the many checks she is mandated to do.
She, along with four others in the department, check the eligibility of the beneficiaries, and verify and upload details in the system. Once that is done, ward managers collect, scan and upload all necessary medical documents required for submitting a claim request.
Tamil Nadu, which has been running the Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS) for over seven years before the Centre’s Ayushman Bharat (Pradhan Mantri Jan Arogya Yojana) was announced, still uses the existing back-end systems to process claims after the State scheme was integrated with Ayushman. The writer visited hospitals (government and private) in the State to review the integration of CMCHIS with Ayushman.
While the existing systems have smoothened the integration process for patients in the State under PMJAY-CMCHIS, those from outside the State have been witnessing teething issues.
Data / system flow
Ayushman uses the deprivation conditions in SECC (Socio Economic and Caste Census) as eligibility criteria. In other words, it provides cover to deprived rural families, and has identified occupational categories of urban workers’ families, as per the latest SECC 2011 data. But given that the data is outdated and has gaps, many greenfield States (that have had no health insurance scheme in the past) have found it challenging to work with the SECC data. For instance, in Bihar, (where the writer visited earlier), officials have been suggesting the use of the NFSA data (National Food Security Act), which would be more reliable. In Jharkhand, the PDS (public distribution system) is being used, which has eased up the process of beneficiary identification.
In Tamil Nadu, while 77 lakh beneficiaries must be covered under Ayushman as per SECC data, the State covers close to 1.47 crore families up to ₹5 lakh, as it considers beneficiaries under its earlier CMCHIS – people with an annual income of less than ₹72,000. “This has enabled smooth implementation of the scheme as a beneficiary can produce the CMCHIS card to claim benefits under Ayushman,” explains Sainath Iyer, General Manager of MDIndia, one of the three TPAs facilitating the scheme’s implementation.
P Vasanthamani, Dean at Kilpauk Medical College, says “the CMCHIS scheme has been running smoothly over the last several years.
Hence, integrating Ayushman has not been an issue. But since under Ayushman, people from other States can also come and get treated free of cost, we need to see how the system works. It is still early days.”
“Currently Tamil Nadu is using its existing systems to process claims for people within the State. Beneficiary Identification System (BIS) is required mainly when people are coming in from other States,” explains Dhakshinamoorthy, Deputy Project Head, MDIndia TPA.
Portable cases
Portability is allowed under Ayushman, where a person from one State can get treated in another State. As many States lack internal capacities for higher sophisticated procedures, there could be large number of beneficiaries coming to Tamil Nadu. There are some challenges here.
In a particular case as cited by Dhakshinamoorthy, the writer saw the system throw up 323 results, for a particular name and district in Assam. The initial beneficiary search, hence, took a day or so for this patient coming from Assam for treatment. The BIS search needs to throw up less than 5 results to help narrow down to the actual beneficiary, which, in some cases, may be difficult.
Even if this is done, reaching out to the respective State Health Agency (SHA) for claim approval may take time and delay the process. Currently, for cases within the State, the claims are settled within 7 days of the final submission (as under CMCHIS).
There has not been a single case of patients from other States coming for treatment at Billroth, a private hospital in Chennai, Chengalpattu Government Hospital, and SRM Medical College in Kanchipuram, which the writer visited.
Hence, there is some uncertainty over how the process will pan out in the case of patients seeking treatment from other States.
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