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1、JAGADISH S Regional Manager Medi Assist,Yashswini,Overview of the project,YCFHCS is a successful micro insurance scheme in Karnataka (PPP). Started in the year 2003 with 1.6 million lives. The amazing success is possible through a tight partnership with the following stake holders Stake Holder : Gov
2、t. of Karnataka, Service providers ( Hospitals, Bank & TPA), Trust This scheme provides cashless facility to eligible Yeshasvini card holders across 484 hospitals in Karnataka for nearly 1600 identified surgeries Apart from the above - medical emergencies like snake bite, dog bite, bull gore, electr
3、ic shock, insect bite is covered.,Type of PPP - OMM,OMM: Operations, Maintenance & Management Operations: Carried out by private viz TPA and Hospitals Maintenance: Govt. of Karnataka Management: Yeshasvini Trust, managed by Trustees representing Public and Private.,Partnership/Actors Involved,Truste
4、es: 1. The Principal Secretary to Govt. Co-operation Department (Chairman) 2. The Registrar of Co-operative Societies, 3. The Managing Director, KSC Apex Bank Ltd 4. Additional Registrar of Co-operative Societies (C&M), 5. The Managing Director, Karnataka State Milk Producers Federation, 6. Dr. C.N.
5、Manjunath (Director) Jayadeva Institute of Cardiology, 7. Dr. Devi Prasad Shetty, Chairman, Narayana Hrudayalaya, 8. Dr. M.D Dixit, Director, KLE Heart Hospital, 9. Dr. Guru Dev, Nephrologist, Vikram Hospital, 10. Dr. L.H. Bidri, Dr. Bidris Ashwini Hospital. TPA: Hospitals: Media Assist India TPA Pv
6、t Ltd Govt (25%) Private (75%) Total 484,Project Objective,To deliver quality healthcare to the organized sector (Cooperative members) through minimum contribution. To extend cashless facility (less paper transactions) No reimbursement under the scheme. Capacity utilization Govt. Setups VAS Discount
7、 for Investigations and free OPD checkups at all network Hospitals.,Project Set-Up and Arrangements,07/05/10,Medi Assist India TPA Pvt. Ltd.,Enrollment Payment, Pre- authorization Query response Enhancement, Workflow management Reports, Document, Billing, Claim submission Claim query response Claim
8、authorization, Payment reconciliation, Pre-authorization approval Pre-authorization/ enhancement authorization, Claim query & processing, Payment Processing Payment disbursement / EFT,1,4,3,2,Electronic Platform,Hospital,T P A,Pre-Care,Treatment,Claim Management,Payment Management,Govt / Trust,Key M
9、ilestones,Increasing the number enrolled members from 16 Lakhs to 30 Lakhs in six years is a big achievement. The PA process has slowly evolved from the fax based processing to 100% electronic. Introduction of EFT for payment to Hospitals. Inclusion of stree shakthi groups (Self Help Group )in to th
10、e coverage since year 2011 Maintaining margins / administrative cost positively over the last three years.,Challenges and Mitigation Plans,Retention of enrolled beneficiaries Make it self reliant Increase scale Extend to other self help groups Revision of package rates,Progress to Date,Lessons Learn
11、t/Best Practices,Enrollment and data entry to NIC site: The enrolled data takes at least 4 months to be entered in to the NIC site. In this window period members to avail treatment have to ascertain their identity with a letter from the society. This can be avoided if the enrollment goes online or o
12、ther methods of enrollment are introduced such as smart cards, biometric cards etc. This make the process more efficient and transparent. Waiting period: As in any mass Health insurance schemes moral hazards also happen in Yeshasvini as there the no waiting period. A waiting period of at least 30 da
13、ys for all surgeries (except emergencies) may be suggested. Entire family enrollment: By waiving the minimum 4 member family concept for enrollment, it has made it convenient for the members to enroll only those individuals who are likely to avail treatment / fall sick. This is not in the interest of the community as a whole (risk pooling?),Thank You,http:/www.yeshasvini.kar.nic.in/,
