A sub-group on fraud control in health insurance, forming part of the joint working group of National Health Authority and the Insurance Regulatory and Development Authority of India (IRDAI) has advocated a strong law to act as a deterrent.
A strong legislation — National Health Insurance Anti-Fraud Act — is “required to effectively to deal with the whole gamut of activities for preventing, detecting and deterring fraud.” This would benefit the entire ecosystem, including private paid health insurance, the sub-group’s report said.
Anti-fraud task force
Suggesting that such a law should provide for setting up of a special anti-fraud task force to take punitive action, carry out recoveries, searches and seizures, the report said joint collective measures by all payers would have great impact on fraudulent practices of providers “which are the major players for fraud.”
While IRDAI is the regulator for the insurance sector, the National Health Authority (NHA) is the nodal agency for implementing the Pradhan Mantri Jan Aroygya Yojana, or Ayushman Bharat as the healthcare scheme is known.
In the set of recommendations and measures for collaboration, the sub-group said the definition of fraud and abuse should be standardised.
Also, the contracts entered into by a payer — with policy holder, empanelled hospitals, intermediary, employee — should mandatorily incorporate a standard definition of fraud, clauses, and the resulting punitive action that those indulging in them could face.
The report also emphasised the need for creation of a common talent pool for effective investigation and a certification programme for ensuring minimum standards.
The impact of healthcare fraud is not only financial but also on the people’s health, and was an issue of “grave concern.
As the coverage/penetration of health insurance expands to more people, for more services, the element of fraud and abuse will also go up exponentially if handled inadequately,” the report said.
With the launch of Ayushman Bharat, the number of people covered under health insurance – private paid, organised through insurance companies under the aegsis of IRDAI or government funded, organised by State governments, now stands at 65 crore, including 15 crore under private paid insurance and 50 crore under PMJAY.
