- Over 9.84 crore hospital admissions approved under Ayushman Bharat with Rs 1.40 lakh crore paid
- Scheme offers up to Rs 5 lakh cashless hospitalisation to nearly 55 crore economically weaker Indians
- IMA highlighted problems such as delayed payments, low reimbursement rates, and complicated claim processes
Over 9.84 crore hospital admissions have been approved under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY), with payments exceeding Rs 1.40 lakh crore, the government informed parliament on Friday.
The scheme, focused on universal health coverage, offers up to Rs 5 lakh annually in cashless hospitalisation to nearly Rs 55 crore economically weaker individuals, covering the bottom 40% of India's population.
More than 41 crore Ayushman Cards have been issued, with Uttar Pradesh leading at 5.33 crore, followed by Madhya Pradesh, Bihar, and Odisha. Lakshadweep issued the fewest at 36,000.
The scheme works through 31,466 hospitals, including over 14,000 private facilities, under Trust, Insurance, or Hybrid models, allowing state-specific flexibility.
However, the Indian Medical Association (IMA) has raised serious concerns in a white paper to the National Health Authority (NHA).
They highlighted problems such as delayed payments, low reimbursement rates, and complicated claim processes that threaten hospital finances.
In Gujarat, Rs 300 crore in claims from 2021 to 2023 remain unpaid.
Only 5% of these claims have been settled within the required 15 days. In Kerala, there are Rs 400 crore in pending dues, and nationwide over Rs 1.21 lakh crore in claims (64 lakh cases) are still outstanding, according to an RTI filed by Ajay Basudev Bose.
The IMA also pointed out that package rates are too low and do not cover treatment costs, especially for complex procedures in private tertiary hospitals.
"IMA should be invited while deciding rates, packages and we should ensure timely payments, ease of claims and simplfied procedures," IMA national president Dr Dilip Bhanushali told NDTV.
Uniform pricing discourages high-quality hospitals, resulting in only 67 of Delhi's 1,000+ private hospitals participating due to operational and financial challenges. Claim rejections caused by technical errors further increase revenue losses.
IMA Recommendations:
- Automate payments and create real-time tracking for transparency.
- Revise reimbursement rates to reflect actual costs, updating them regularly.
- Simplify claim documentation and provide 24/7 digital support (e.g., WhatsApp, SMS).
- Set up grievance redressal at district, state, and national levels.
- Incentivise accredited and rural hospitals with higher payments and faster approvals.
- Move to direct benefit transfers using fintech, avoiding third-party intermediaries, to improve efficiency and sustainability.
- Encourage competition and address market failures, reducing payor biases and oligopsony effects that threaten small and mid-size providers.
Minister Prataprao Jadhav acknowledged implementation challenges in the Rajya Sabha, urging states to adjust models for better efficiency.
The IMA's white paper, submitted to the Rajya Sabha Standing Committee on Health, is awaiting a response from the NHA.
Doctors warn that without reforms, the scheme's aim of providing free, quality healthcare for India's poorest is at risk.
