An Important Tool to Detect Integrity Violations in Government Health Insurance Programmes

Government health insurance schemes operate on cashless and paperless models. In a cashless model the entitled beneficiary gets treatment free in empaneled hospital and patient has not to pay for treatment cost

Health insurance schemes are expanding access of health care services since launch of Government of India's flagship health insurance programme, 'Ayushman Bharat-PMJAY' in 2018. As India navigates through the health & financial impact of COVID-19, every State is focusing to provide tertiary and secondary care to its vulnerable population through State Health Insurance Schemes. This has transformed the landscape of health care delivery and its finance through health insurance policies. Participation of both public and private hospitals in these health insurance schemes has made care affordable and accessible to most vulnerable and poor population of the country since these schemes are financed by States.

Awareness programs for these schemes have increased utilization of care. One common challenge for these popular schemes is constant threat of integrity violations. Intentional fraud, abuse and wastage in such schemes not only impact it financially but it often leads to endangering the health of poor beneficiaries. Any tax funded scheme cannot absorb the cost of abuse and wastage and tools that detect manipulations and abuses early are necessary for efficient claim management processes of such schemes. One important tool to detect integrity violations is Desk Medical Audit.