We are reducing frauds and abuse with data analytics: Indu Bhushan, CEO, Ayushman Bharat

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Pradhan Mantri Jan Arogya Yojana (PMJAY) under Ayushman Bharat, a national health protection scheme to cover over 10 crore poor and vulnerable families (approximately 50 crore beneficiaries), providing coverage of up to Rs 5 lakh per family per year for secondary and tertiary care hospitalisation, is banking heavily on IT for monitoring, maintaining health records and reducing the fraud and abuse of the scheme. Built on open source technology, this massive scheme is currently using data analytics and is exploring the use of emerging technologies like blockchain and chatbots for making it more simple and friendly to the masses.

Speaking exclusively to Express Computer, Ayushman Bharat CEO Indu Bhushan talks about how IT is helping in overcoming the challenges before the health insurance scheme and how it can be a disruptor in the healthcare space.

Bhushan says, “The year 2018 was tremendous for us as we could roll out Ayushman Bharat in such a short time. The initial momentum has also been really well, without any glitches in terms of IT outage or in any basic design of the scheme. There are, of course, challenges for scheme like this with its scale and ambition.”

The scheme covers 500 million people and a complex combination of 36 different schemes involving so many stakeholders, beneficiaries, service providers, etc. Without a strong IT backbone, it cannot be achieved, according to Bhushan. “IT is a mainstay of our scheme as it helps in identifying, verifications, e-cards, recording health data, tracking the persons from admissions to discharge and making the payment. Frauds and abuse control have been reduced with the help of IT. Last, but not least, IT also helps in seeking feedback and grievances from patients and national portability as many people are coming from one state to another state confirming their identity,” he informs.

Currently, the main challenge for Ayushman Bharat CEO is to have a sufficient number of quality hospitals to provide the required service and to design the scheme in a way to check frauds and abuse. “We want to ensure that we can minimise the incidence of fraud and abuse. Secondly, to ensure that the IT system remains stable and robust. We have been working on establishing the schemes, putting the guidelines together, putting the IT platform together, negotiating with different states, identifying the Mitras and their onboarding and training. A large amount of work was done in the last 7-8 months. Now, we are trying to see how we can improve the quality of services, reduce the incidents of frauds and deepen the reach of the scheme. These three things are on top of our mind,” he comments.

The scheme is strictly monitoring fraud detection. It has appointed five data analytics providers including LexisNexis, Optum, SAS Institute, MFX and Greenojo. “We are working with the five different data analytics team in-house currently and providing data to states. We have detected some potential frauds. Recently, we did an audit in Jharkhand and found there are potential frauds in two of the hospitals as the numbers of patients were larger than their bed capacities. We have suspended the hospitals until the enquiry is complete. With the help of software-based data analytics, we are getting triggers from all the different states and are sending feedback to all the states for taking quick actions. We have sent the first round of feedback recently and we will be sending them every week,” Bhushan explains.

The scheme is built on open source technology, having multiple technology providers. For beneficiaries’ identification, it is working with CDAC and NIC. For transaction management systems and hospital empanelment, TCS has been appointed as the service provider. The scheme is linked to Aadhaar.

On privacy and data security, Bhsuhan reiterates, “Our programme is the first in the healthcare space which has data security and privacy policies. It is similar to Aadhaar; however we don’t store the data, we use a token instead. All the information which will not be used in the future is destroyed and the rest of the data is encrypted, so it can’t be misused. We are dealing with sensitive health records, information and Aadhaar numbers. We are following ISO/IEC 27000 ISO 27,000. We have 99 controls at various levels of privacy and security.”

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