Fraud Hospitals To Be Named, Shamed: NHA, IRDAI Recommend Bank-Like Practice For Health Insurance Sector

Ayushman Bharat ‘Name and Shame’ guidelines: Health insurance fraudsters under Ayushman Bharat should be publicly named and shamed in a bid to deter them from committing malpractices, a Joint Working Group (JWG) report of National Health Authority (NHA) and IRDAI has recommended. The fraudsters may include hospitals, health care providers, intermediaries and policyholders. The report defines ‘Name and Shame’ as “a system for public dissemination of information about an entity/person/organization involved in committing fraud under a health protection scheme of the Government or under an insurance program/policy.”

If implemented, the JWG recommendations may affect a big change in the overall health insurance sector as well in the long run and benefit common people. While naming and shaming of defaulters is a regular practice in the banking sector, there is no clearly defined policies or guidelines for such practices for the health insurance sector. The NHA-IRDAI report may become the first step in this regard.

The JWG has made recommendations for naming and shaming of fraudsters for discussion and deliberation among the health insurance stakeholders in India. The report notes “insurance industry would benefit by developing the guidelines for intermediaries, rogue policyholders.”

NHA-IRDAI report: Key recommendations

In what may be a “small beginning at different – incremental levels” to prevent health insurance frauds and give more power to policyholders, the JWG has made the following recommendations:

When the fraudulent activity has been confirmed, the government authority /agency/insurance firm /TPA (third-party administrator) should take following steps:

– Issue warning or show-cause notice to the hospitals found to be indulging in fraudulent activities, depending on the seriousness of the fraud.

– The warning, or show cause notice, should be followed by the process of suspension and de-empanelment as per the contract.

The hospital would removed from the list of network hospitals if it fails to “satisfactorily explain/respond to show-cause notice or continue to indulge in malpractice”.

– The list of de-empanelled/blacklisted hospitals will be mentioned on the website of the Government Authority/SHA/Agency/Insurance firm/ TPA. The JWG has recommended that this list should be “prominently displayed and easily accessible on the website”.

– Hospitals which have been served with warnings, show-cause notice or suspended temporarily will also be mentioned in a separate list on the websites.

– The de-empanelled hospital may be allowed to re-apply for empanelment after a gap of minimum 6 months-1 years after it submits proof of having “mended unethical ways”.

– The IRDAI may prepare an industry de-empanelled/blacklist every and display on its website. The NHA will prepare a similar list for hospitals empanelled with PM-JAY/Government schemes.

– The JWG has also recommended to sensitize and inform policyholders and health workers about the de-empanelled hospitals. Setting up of Whistle Blower mechanisms has also been recommended.

Commenting on the recommendations, Dr Indu Bhushan, CEO, NHA had stated, “The recommendations in the report are a step forward in enabling quality healthcare and access to the patients. These reports would help further strengthen the transparency, efficiency and effectiveness of AB-PM-JAY, benefitting millions in India directly.” – Financial Express