Working Group on Innovations in IT

1. Working Group on Innovations in IT

2. Innovation is the outcome of a Habit, Not a Random ActSukant Ratnakar

3. OVERVIEW OF PMJAY 1.0 IT

4. Detailed transaction data from States that use their own IT software to implement PMJAY (8 states) PMJAY Data Warehouse PMJAY Insights Manual approval if record cannot be auto-approved E-KYC Get Photo, Name and Address Bio Auth of Patient Validate PMJAY e-Card PMJAY Beneficiary Identification (BIS) PMJAY Fraud Analytics PMJAY Transaction Management (ONE TMS) 50 Cr ELIGIBLE BENEFICIARIES Provides Aadhaar and Family ID Fills Claim form online. Scan and uploads required documents. Issues PMJAY e-card in less than 30 mins System designed to provide end to end transparency on each claim with all stakeholders Beneficiary Adjudicate Claims (ISA) Process Payments (Insurer / SHA) Hospital Hospital Empaneled for PMJAY Hospital fills online form District Empanelment committee inspects hospital and approves PMJAY Hospital Empanelment (HEM)

5. PMJAY 1.0 IT Landscape PMJAY Fraud Analytics PMJAY Call Centre PMJAY Insights Inbound for queries Outbound for feedback PMJAY Beneficiary Identification (BIS) Mera PMJAY website Am I Eligible 50 Cr ELIGIBLE BENEFICIARIES Beneficiary Mera PMJAY App PMJAY Transaction Management (TMS) Empaneled hospitals near me Complaints PMJAY Data Warehouse PMJAY Hospital Empanelment (HEM) Grievance Website Government Community Cloud Infrastructure Data Security and Privacy by design

6. Inputs from the working group members on existing PMJAY 1.0 IT system

7. Improvement recommendations for BIS • Develop Link with Aadhaar for cases who were initially verified without Aadhaar • Create a Mobile App to capture BIS Photo including a liveness check for non Aadhaar cases • Make Ration Card compulsory while adding members – reduce possibility of fraud • Develop a search and approve for BIS approvers. This will help clear cards in emergency cases

8. Improving Quality of Data in BIS • Create a online training and validation course for a BIS user • Only operators who have completed the training and achieved a minimum score should be enabled on BIS • Track every transaction in BIS against an operator and provide a quality score for each operator • Operators scoring low in actual will need to go back to training.

9. Experience Enhancements in OneTMS • Display all data from BIS including if this was an Added Member when processing a case • One Page View for attachments – Display all attachments in a single scrollable window to make it faster for reviewers • Capture Surgery Timings – It is useful for fraud related analysis • Include SMS Triggers with Beneficiary on events like Registration, Pre-Auth and Discharge. Engagement with the beneficiary will also reduce misuse and fraud

10. Create a Module for Medical Audits Create a Medical Audits Module, ensure 10% of all hospitals are audited every quarter. Pick up the hospitals based on criteria including • Total number of cases done • Total number of death cases • Total grievances pending for resolution • Rejection of preauths and claims etc. Ensure field verification of case papers as part of the process

11. Adopting Clinical Protocols Integrate a clinical protocol module into the claims system Develop Specific queries to be filled in by the hospital for each procedure Allow pre-auth to be raised only if the hospital has followed the specified steps for the procedure. Recommended that learnings may be studied from Maharashtra and piloted by NHA

12. Other Inputs • Introduce Grading on Hospitals based on infrastructure at hospitals • Automatically read attachments using OCR technology and pre-fill certain fields to support adjudication • Improve Grievance module – enable beneficiaries to register greviance by call centre and field officers to raise greviances during field visits • Develop a module and push States towards Health Camps

13. PMJAY IT 2.0

14. IRDAI NHA Joint Working Group Report • IRDAI and NHA setup a Joint working group to cover various areas of common interest • A Sub group was setup for “Common IT Infrastructure for Health Insurance Claims Management” • The Committee included representation from IRDAI, NHA, Insurers, TPAs, Providers and external experts. • The reports of the JWG were published for public consultation in Sep 2019 and are available on the PMJAY Website • PMJAY IT 2.0 takes the key recommendations made in this report as part of its implementation plan

15. Need for PM-JAY IT 2.0 • Standards adoption from a domain & technology perspective • Be future ready – interoperable, exchange ready, next-gen tech • Be Agile, Stable and Scalable • Services being digital end-to-end (including ‘Paperless, Cashless and presence less) • Have an established partner perform on agreed SLAs • Pay for services • Enhance User Experience (UX)

16. PM-JAY 2.0 Design Principles Standards Adoption Electronic Claim Open APIs & Standards • FHIR Release 4 • SNOMED – CT • ICD 10 • LOINC • EHR Standards (2016) Non-Repudiability Machine Readable Schemas Verifiability Agile IndEA Explainability Digital Service Standards Innovation Consent based Data Sharing Micro-services Architecture Security & Privacy by Design Data Privacy & Encryption Open-Source Policy

17. Proposed Health Claim Processing in PMJAY 2.0 Real time data for monitoring and evaluation Define standard e-claim, e-discharge and other key forms that can be used to initiate claims for any Insurer or PMJAY Create a Health Claims platform that validates requests, routes to appropriate party, guarantees payment and gathers data for real time monitoring Submit using Open API Health Claims Platform Hospital Route to Insurer / TPA In Auto Adjudication FWA prevention Create a market where Hospitals can choose software that will help them process any insurance claim and get end to end visibility on claim status till payment. Hospitals have 3 choices -- Procure a specialized software, use free software from govt or modify their HIS system to support APIs Adjudicate Claims Create a market where Insurers / TPAs can choose software that will help them improve on auto adjudication and fraud waste and abuse prevention Based on the recommendations of the NHA IRDAI JWG

18. New approach to Empanelment & Contracts Define e-facility form. This is a standardized machine readable format with details about the specialties, infrastructure and manpower of a provider. They can use any software including HEM from PMJAY to create and digitally sign the form Any Insurer / TPA can obtain the e-facility form for any provider from the HCP. Any verification of the information done by them can be submitted back to the HCP Health Claims Platform Submit using Open API Submit using Open API Hospital Digitally Sign and Upload Contract Between Parties Contract visibility only between relevant parties Verify and digitally sign Contract Remove Paper based contracts. Save Trees.

19. Policy Markup Language (PML) Policy Markup Language is a machine readable way to specify the rules related to a health policy. For example the PML for PMJAY will specify which packages are reserved for public, price for the package, incentive criteria, etc PMJAY IT 2.0 looks to make all key documents in a health claim – standardized and machine readable. This will greatly enhance the capabilities of Auto Adjudication and FWA for payers. E-Policy In Policy Markup Language E-claim E-facility E-discharge Auto Adjudication & Fraud Waste and Abuse detection

20. MULTI HCP ENVIRONMENTS Multiple HCPs in the ecosystem ensures there is redundancy and options for Payers and Providers. NHA is developing the first HCP as part of PMJAY 2.0 IIB is keen to develop a HCP as part of its roadmap

21. Support for Personal Health Records

22. Courses in Medical Coding • Many elements in the e-claim and e-discharge including diagnosis need to be coded correctly using the recommended standard (ICD-10 or SNOMED). • Every provider wanting to participate in PMJAY or any other health insurance will require to have one or more team members to take a certificate course in Medical coding • This will greatly improve the quality of the incoming document and also help move the industry towards improved adjudication

23. Lets go invent tomorrow instead of worrying about what happened yesterdaySteve Jobs