RSBY Claims Management

"Government has tried to provide a health card cover to selected beneficiaries either at the State level or National level. However, most of these schemes were not able to achieve their intended objectives. Often there were issues with either the design and/ or implementation of these schemes. After considering all this and reviewing other successful models of health insurance in the world in similar settings, Rashtriya Swasthya Bima Yojna were designed"

Project Description

Rashtriya Swastya Bhima Yojane (RSBY) is a health insurance coverage scheme launched by the Ministry of Labour and Employment (MoLE), Govt. of India in the year 2007. The main objective of this scheme was to provide health insurance protection to BPL households against health shocks that involve hospitalization. The scheme was introduced with lot of guidelines to ensure that the benefits were not misused by anyone and the general public is benefitted the most. This scheme is a cashless scheme where the premium is paid by the government directly to the healthcare providers through insurance companies after the beneficiaries avail medical facilities.

Challenges

Spreadsheet based claims data for IC
No automated payments
Incomplete MIS reports
Absence of analytical reports
No document management system
Implementation of MoLE triggers

Effia’s Solution

Effia’s web based solution helped the insurance companies, TPA’s, hospitals and investigators to view real time data in the form of extensive analytics and reports, facilitating the stake holders to formulate business strategy. The solution ensures complete transparency and also deals with the current triggers/conditions set by MoLE. The solution developed by a team of experts is designed in such a way that any policy changes by the government at a later date can be implemented in practically no time without any hassle.

Our advances in healthcare are made from a willingness to face change with innovative solutions which shape the future of health care. We enhance operational efficiencies, streamline internal processes and modernize business. Our full services offering comprise IT services, consulting and infrastructure services.

We work with healthcare insurers and other payers to facilitate a seamless migration of their services to a future state driven by wellness, cost predictability and value to all stakeholders.

Impact of the solution

Complete transparency in the system
Better control over the system for all stake holders
Easy identification of post enrollment data
Automated claim approval process
Proper implementation of triggers set by MoLE
Easy monitoring of benefits and facilities availed
Proper online document management system