Frustrated with PMJAY payment delay, AHPI seeks 1% interest

Frustrated with delayed reimbursement of treatment done for the Ayushman Bharat beneficiaries, the countrywide network of private hospitals has reached out to the government demanding an interest on late payment.

The Association of Healthcare Providers of India (AHPI), which claims to represent nearly 15,000 private hospitals, has demanded the government pay 1 percent interest on payment that is delayed beyond one month under the Centre’s flagship health insurance scheme.

Launched in 2018, the Ayushman Bharat scheme provides secondary and tertiary level hospitalisation benefits to beneficiaries, identified based on the 2011 Census, through the empanelled private and government hospitals.

“The biggest concern raised by member hospitals is about inordinate delay in receiving reimbursement. This hampers the cash flow and poses serious operational issues for all hospitals in general and for small/mid-size hospitals in particular,” the AHPI wrote to the government.

AHPI director general Girdhar J. Gyani told ThePrint that a large number of about 22,000 hospitals empanelled under the scheme are mid-size private hospitals with a bed capacity of less than 100.

“The average delay in payments that the empanelled hospitals report is about 6-8 months and the situation is particularly bad in some states,” Gyani said. “We are, therefore, suggesting that a clause — which was part of the original scheme to pay interest at the rate of 1 percent if payment was delayed by more than one month but was removed later — should be implemented.”

If this provision is implemented, Gyani said, it will bring accountability in the system to ensure timely payment to hospitals.

“Many tertiary care private hospitals have been wary of joining the scheme due to the issues of delayed payment and low package rates. The move will motivate many such establishments to empanel under the health scheme,” he said.

Under the scheme’s payment plan, the Centre and states share the cost as per 60:40 ratio, barring the Himalayan and North-eastern states where this ratio is 90:10. In the revised Union budget for 2023-24, Rs 6,881 crore was allocated for the scheme. The Centre had proposed Rs 7,500 crore for the scheme in the 2024 Union budget.

ThePrint reached out to Deepti Gaur Mukherjee, chief executive officer of the National Health Authority, which runs the Ayushman Bharat, over phone calls. This copy will be updated if and when a reply is received.

‘Scheme needs to improve’
In March, the government had formed a committee, under Dr V. K. Paul, member (health) of the think tank Niti Aayog, to review the functioning of the scheme and suggest ways to extend services and beneficiary base, among other things.

The scheme aims to cover nearly 50 crore people, considered the poorest, or 40 percent of the population but estimates show that only about 60 percent of those entitled may have been registered for the scheme.

The AHPI, in its letter to the Paul committee and the NHA, has said that the rest of the population in future may also be covered under the scheme as appropriate.

For example, it says that senior citizens above 65 years of age may be brought under the ambit of the Pradhan Mantri Jan Arogya Yojana (PMJAY) and the government may consider providing subsidised healthcare for the ‘above poverty line’ population.

The association has also said that concerted efforts are needed to reach out to the beneficiaries for enabling them to avail the benefits under the scheme.

The AHPI has also said that the package rates need to be revised to make it sustainable for the hospitals to join the scheme.

“The package rates need to be fixed based on a scientific study by a competent body like Institute of Cost Accountant of India. The rates also need to be linked with inflation and revised on an annual basis,” it has said, adding that while PMJAY rates are generally considered low, even the rates fixed under PMJAY Health Benefit Package 2 have not been implemented in many of the states.

Some of the package rates, the association has argued, is “illogical” and they need review with participation from private industry representatives.

“Same is the case for fixing reimbursement for unlisted procedures. With the rates not being viable, quality and patient safety will take a back seat,” AHPI has said.

Also, as per the association, as more than 85 percent of tertiary care beds are with the private sector for whom the rates prescribed under PMJAY are not viable, the NHA should consider allowing co-payment to enable beneficiaries to get benefit of seeking treatment from specialist hospitals for serious ailments.

The AHPI has also said that there is variation in the way hospitals are empanelled in different states, underlining that this needs to be standardised. There is a need to designate an independent grievance redressal agency for empanelled hospitals, it suggested. ThePrint