Guidelines On Hospital Empanelment And De-Empanelment

Unlock the pathway to quality healthcare with our comprehensive framework for empanelment and de-empanelment under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY). This document delineates the processes, criteria, roles, and responsibilities, ensuring that beneficiaries receive exceptional healthcare services.

It provides a streamlined system for both public and private healthcare providers to join the PM-JAY network. By following these guidelines, providers can meet the high standards required for delivering quality care to vulnerable populations.

Overview Of Ayushman Bharat PM-JAY

Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) was launched by the Government of India in September 2018. The core aim of this scheme is to reduce the financial burden on the poorest and most vulnerable population and ensure their access to quality health services, thereby accelerating India’s progress towards Universal Health Coverage (UHC).

Empanelment Of Healthcare Providers

The empanelment process ensures that healthcare providers meet the required standards to offer services under the PM-JAY scheme. It includes specific criteria and approaches:

1 Approach For Empanelment

• States/Union Territories can empanel healthcare providers within their jurisdiction.
• SHAs may request NHA approval for empanelling healthcare providers outside their state.
• Public healthcare facilities providing PM-JAY services can be empanelled automatically.

2 Criteria For Empanelment

• Healthcare providers must meet minimum eligibility requirements, such as infrastructure, staffing, and equipment standards.
• Specialty-specific eligibility criteria apply for providers offering specialized services like oncology or neurology.

3 Incentive Structure For Empanelment

• Empanelled healthcare providers receive incentives based on quality certifications (Bronze, Silver, Gold) that correspond to higher reimbursement rates for health benefits packages.

Institutional Set-Up For Empanelment

A structured institutional setup is crucial for effective empanelment and monitoring of healthcare providers. This includes the roles and responsibilities of various committees:

1. Role Of National Health Authority (NHA)

The NHA develops guidelines, supports SHAs, and may directly empanel providers in non-PM-JAY states or for National Health Care Providers (NHCPs).

2. Role Of State Health Agency (SHA)

SHAs are responsible for creating awareness, verifying applications, and approving or rejecting healthcare provider applications. SHAs conduct district-level analyses to ensure equity and access to healthcare services.

3. State Empanelment Committee (SEC)

The SEC monitors the overall empanelment process, supervises DEC activities, and handles application rejections or pendency.

4. District Empanelment Committee (DEC)

DECs validate and scrutinize application documents, conduct field and desktop-based verifications, and recommend approval or rejection to the SHA.

Process Of Empanelment For Healthcare Providers

The empanelment process involves multiple steps, from application submission to final approval, ensuring that healthcare providers meet all necessary criteria:

1. Application And Registration On the Portal

Healthcare providers must register on the Hospital Empanelment Module (HEM) portal and complete the detailed application form.

2. Approval Process Of the Application

Applications undergo desktop and physical verification by DECs within 15 working days. Options for fast-track empanelment are available for accredited hospitals or those empanelled under state schemes.

3. On-Boarding Processes After Approval

Upon approval, healthcare providers sign an MoU with the SHA, designate a nodal officer, and receive training on PM-JAY systems and processes.

Disciplinary Proceedings And De-Empanelment

Maintaining the integrity of the PM-JAY scheme involves stringent disciplinary measures for healthcare providers who fail to meet standards:

1. Rationale For Disciplinary Actions

Disciplinary proceedings and de-empanelment are conducted to ensure quality care and prevent fraud and abuse in the scheme.

2. Investigation Of Suspect Claims

Suspect claims are investigated through desk audits and field visits, with detailed reports submitted within 10 working days.

3. Suspension And De-Empanelment

Healthcare providers may be suspended for up to 6 months based on investigation findings, with a detailed process for appeals and further actions.

Annexures For Healthcare Providers

Detailed annexures provide additional information and criteria for empanelment, verification processes, and other specific requirements:

1. Criteria For Empanelment

Detailed criteria for minimum standards and speciality-specific requirements are provided, along with relaxations for aspirational districts.

2. Additional Documents

Annexures include lists of classified cities, processes for desktop-based verification, and self-declaration forms for specific facilities.

Conclusion

The guidelines serve as a framework to assist State Health Agencies (SHAs) in the empanelment of hospitals and diagnostic centres, ensuring that healthcare providers meet minimum standards. These standards include infrastructure, staffing, equipment, and adherence to quality protocols. 

It also provides a detailed process for disciplinary actions and de-empanelment to maintain the integrity of the scheme. The aim is to enhance the accessibility and quality of healthcare for the most vulnerable populations.

Frequently Asked Questions (FAQs)

Download The Official PDF From Here