Health schemes face hurdle in Punjab as pvt centres stop cashless treatment

An association representing private hospitals in Punjab has announced suspension of all cashless treatment being provided under the government’s health insurance scheme citing the state's pending dues of Rs 600 crores.

Private Hospital and Nursing Home Association (PHANA) Punjab has said that private hospitals and nursing homes of the state will no longer offer cashless treatments under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) and state government health insurance scheme.

Meanwhile, according to reports, Punjab’s Health Minister Balbir Singh said the State Health Agency (SHA) will soon hire medical professionals to expedite the claims processing.

Queries e-mailed to the Union Health Ministry and the National Health Authority did not elicit any response immediately. Business Standard also could not connect with the state government on Thursday for a response on the matter.

The hospital body PHANA claimed that it took the step due to unresolved payments of approximately Rs 600 crore owed by the state government, pending for the last six months.

Punjab had integrated its state health insurance scheme with PMJAY in August 2019, christening it as Ayushman Bharat PM-JAY Mukh Mantri Sehat Bima Yojana (AB PM-JAY MMSBY). 

The scheme provides eligible beneficiaries with an insurance of Rs 5 lakh per family per year for secondary and tertiary care hospitalisation, enabling cashless treatment across public and private empanelled hospitals in India. 

While the PMJAY covers households based on the deprivation and occupational criteria of the Socio-Economic Caste Census (SECC) 2011 for rural and urban areas, the state scheme adds coverage of additional categories such as ration card holders, small and marginal farmers and construction workers registered with the state. 

The cost of premium for 16.65 lakh SECC beneficiary families is borne by both central and state governments in a 60:40 ratio. The premium cost of remaining 22.12 lakh beneficiary families is completely borne by the state.

The MoU states that the payment for each case must be completed within 15 days of a patient’s discharge. 

“We complete the claim settlement from our side on the day the patient is discharged, which includes uploading documents on the SHA’s software. The agency then has 15 days to process the claim, dismiss or accept it and disburse the amount to the hospital,” an official from a Jalandhar-based empanelled hospital said. 

“For every payment that remains pending after 15 days, the agency has to pay an interest of 1 per cent,” he added.

The case involving Punjab comes months after the Haryana state chapter of IMA had resolved an issue involving approximately Rs 133 crore in pending payments with the state government in July this year. 

Commenting on the reason behind the delays, an official with one of the private hospitals empanelled in the scheme said that the problem of untimely payments to the hospitals arose when certain states merged their state health scheme into the PMJAY. 

Several states, including Punjab have integrated the Centre’s Ayushman Bharat scheme with their own scheme to cover families which are not eligible under the former.

“The inordinate delay in receiving reimbursement hampers the cash flow of these private hospitals and creates serious operational issues. In turn, the reduced participation of private hospitals in the Ayushman Bharat scheme could severely impact patients,” the official added.

According to National Health Authority (NHA) data, more than 30,000 hospitals and health centres are currently empanelled under the Ayushman Bharat scheme, of which 13,459 are private. 

The data also suggests that specialities such as cardiology, general surgery and orthopaedics, which also include procedures used to treat elderly with chronic cardiovascular and respiratory diseases are among most used under the scheme. 

Commenting on whether the expansion of the scheme to cover all over 70 years of age could affect the hospitals further, Dr Sunil Rao, chief operating officer, Sahyadri Hospitals said that we anticipate a period of adjustment as we integrate these changes into our system.

“We will closely monitor and assess the impact of this inclusion over the coming months,” he added.