Strengthening Ayushman Bharat through AI adoption

February 25, 2022

By Akshat Singh

Last September the Indian government announced the Ayushman Bharat Digital Mission, aimed at overhauling the country’s healthcare data systems. The announcement brought into focus several efficiency-related concerns that mar the Ayushman Bharat program and were exacerbated by the pandemic. Private partners have expressed concerns over delay and withholding of payments, which often translates into a reduction in coverage and quality of service for patients. Given India’s constraints vis-a-vis the public healthcare infrastructure, private partnerships will be crucial to the program’s success. It is imperative that the Indian government addresses payment and efficiency-related concerns of the program, benefiting partners and end beneficiaries.

The current efficiency issues with Ayushman Bharat are two-fold. First, there is a manpower constraint which is worsened by the over extension of resources. Reliance on rigorous manual audits means that despite existing turnaround time (TAT) guidelines, claims’ pre-authorization, adjudication, and approval is inefficient which disincentivizes private participation. Second, different implementation models across states lead to differences in standards of operation, as well as insurance portability issues, thereby causing coordination inefficiencies. Currently, Indian states can choose from three different modes of claim dispersal: a state-level trust managed by the State Health Agency (SHA), an insurance method that includes implementation by insurance support agencies (ISA), and a hybrid model which is a mixture of both. The trust system is the most popular among states.

The government’s push for using artificial intelligence (AI) to augment the utility of Ayushman Bharat is supported by industry. Furthermore, comparable technology exists in the private sector and is even partially adopted by the government for fraud management. Thus, the government should consider further adoption of digital technologies to strengthen the Ayushman Bharat program.

To begin with, the government can focus on the following areas:

1. Streamline the pre-authorization process. Before beginning treatment, hospitals need to obtain approval for pre-authorization from the government. The process of obtaining the approval can be tedious. It includes a medical audit by the pre-authorization processing doctor, a non-technical verification by a program manager, and re-verification by the SHA/ISA. Additionally, SHAs and district agencies simultaneously audit verifications, and dedicated information technology teams flag suspicious activity. Due to differences in medical opinion, and long processing times, the government has allowed automatic approval after six hours to expedite treatment. However, district and state-level agencies can revoke the authorization at any point— a provision made to screen unscrupulous activity. The possibility of revocation levies financial uncertainty on empaneled hospitals as their authorization may be revoked after they have started treatment. While a layer of human audits may be necessary for prudence, automating repeated tasks of medical and non-technical verification can be beneficial. AI technology for pre-authorization is already in use in India, and globally. The introduction of this technology will not only save time but will also reduce human error.
2. Address claims adjudication, and grievance redressal. Post-authorization, apart from desk audits, agencies send professionals (mostly non-medical) to verify the details of the medical procedure. After discharge, payment approvals follow a similar labyrinth of offices as the pre-authorization. While the center has adopted TAT guidelines (15 days post-discharge), states have their own guidelines which are similarly violated. If payment approvals are denied or withheld, the hospitals can request a re-verification. While it is mandatory for ISAs to independently audit re-verification requests, trust states do not have a similar mandatory directive to audit re-verification requests and choose to do so on a case-to-case basis. Implementing AI solutions to overall claims approval and adjudication will benefit hospitals and patients, while also addressing discrepancies between states. Finally, automating claims processing is estimated to reduce the administrative costs to ₹15-20 from ₹500 per claim, thereby reducing premiums and saving public funds.
3. Strengthen portability mechanisms. Currently, the transfer of cases between hospitals in different states causes insurance portability issues. These arise due to an intra-state difference in premiums, and information management systems. The former is a geo-spatial issue and can be addressed by adopting a national health trust system like Canada or public subsidized private insurance program, akin to the Netherlands. Currently, the government can implement standardized information management systems across all states, regardless of the claim dispersal system they follow. Uniform information management systems would fasten the claims approval process which is even worse in portability cases, and bring relief to insurance companies and patients who incur high out-of-pocket charges.

Ayushman Bharat is an ambitious program that can revolutionize healthcare access in India. However, the current administrative complexity dissuades much-needed private partnerships and hurts end beneficiaries. The government must work towards the rapid adoption of new technology to address current procedural roadblocks. Implementing existing AI solutions, and standardizing information management systems across different states will go a long way.
Akshat Singh is an intern with the Wadhwani Chair in U.S.-India Policy Studies at CSIS