Abstract of Dissertation

Keyword : Health Insurance; National Health Insurance Scheme; India

Objective : 1. To compare the existing state mass health scheme running in the country. 2. To study the type of frauds occurring in the different mass health schemes which reduce its scope of operation and recommending strong Fraud mitigation methods to reduce the same. 3. To determine the need for health insurance and proposing an Ideal Health Insurance Scheme in the country.

Background : If one is to compare the health indicators of India from those that are present worldwide, the picture that will emerge is going to be dismal. The progress in health from the weak starting position in 1947 has been tremendous but still not enough. The government has recognized the need for reform and has introduced several of these in the eleventh and the twelfth five-year plans. Both the public and the private sectors have played an important role today in improving access to the quality of the healthcare sector in India, but still, the country lags behind than other countries. The presence of inequalities in India further exacerbates this problem. The inequalities are both demographic and geographic in the context of India. The Govt. will have to take bold steps to correct these issues. Health spending, as a proportion of the GDP, will have to rise while collaboration between the public and the private sector is the only way by which the said improvements in infrastructure and general health care can be addressed.”

Methodology : 1. Study Design: The study is descriptive and exploratory in nature. In this study, a comparative analysis was undertaken by comparing the National Health Insurance scheme of various states. Process of implementation, current challenges, types of frauds existing with the insurance schemes and designing of ideal universal health insurance scheme 2. Setting: Axa France branch office, New Delhi 3. Duration: February to May 2018(3 months) 4. Data collection procedure: Secondary data was collected on individual schemes from the various respective records, tender guidelines, RFP and Addendum, official records, various publications by researcher and electronic data from the respective official website of various health insurance schemes. 5. Data analysis: Data was analyzed with the help of advanced Microsoft excel function on the type of frauds seen in different mass health insurance schemes.

Findings : On reviewing the Government internal reports, it was found that the Fraud can happen at any step of the scheme implementation. ? At Enrolment Phase Printing of fake cards 1. Involvement of hospitals in the issuance of smart card 2. Issuance of smart card with the same URN to more than one person with the same name. 3. Cards printed but not distributed to the actual beneficiaries, but sold to hospital 4. Purchase of cards by the hospitals, directly from the beneficiaries 5. Charging extra money for enrolling beneficiaries whose name is not in the data shared by Government ? At the level of Hospital empanelment Various state/district officials have their vested interests for the empanelment of hospitals even if sufficient numbers are already empaneled ? At the level of Claims 1. Surgical Packages blocked but no performance of an operation. 2. Card of a patient blocked but the patient was not found in the hospital 3. Smart cards found in the custody of the hospital without the patient being admitted. 4. Patients charged for diagnostics and medicines 5. Claims are not uploaded by the hospitals within a stipulated time, in order to misguide the insurance company. On Comparing Several State Health Insurance Scheme, it has been found that there are some major Strengths and Pitfalls in one or other scheme. Major strengths are: 1. Cashless and Paperless Scheme 2. Robust enrolment process 3. Robust Grievance Redressal Mechanism 4. Government Restricted Packages Major Pitfalls are: 1. Secondary treatment not covered 2. Sum insured less 3. Quality of enrolment data is not good 4. Exclusion of marginalized population The government must recognize. health insurance. as a separate line of business. It must also introduce capital. monitoring and product level norms. for private health. insurance. Accreditation. and benchmarking of health providers are essential and there should be some quality standards and protocols. for follow-ups.” The budget should be directed to training. doctors, providers, health economists, cost accountants, epidemiologists, hospital managers, record keepers in computerization. etc. The Government should facilitate. public-private partnership in a competitive environment. via self-controlled. health trusts. There should be strong claim monitoring and Fraud mitigation methods in order to control the claim ratio.