This article is for Healthcare Providers (HCPs) who are interested in the best way to participate in Ayushman Bharat (PM-JAY). You may already be empaneled, or you may be conducting in-depth research to make a decision.

DocWealth is a specialised financial advisory firm where healers thrive. Read our articles on the introduction to the AB-PMJAY, the empanelment process, & the scheme's challenges for more information.

How to Make AB-PMJAY Financially Viable?

As one of the world’s most ambitious national health insurance schemes, the implementation of PM-JAY  has been bumpy. Delayed claims and miscommunication are just the beginning. Complex issues surrounding Standard Treatment Guidelines (STGs), systematic delays, and logistical challenges remain substantial. 

Yet, there are many steps an Empaneled Healthcare Provider (EHCP) can take to make participation more sustainable.

#1. Consider Your Business Model

• Do you have a sufficient number of beneficiaries to justify participation?

• Are there other, more established empaneled competitors in your area?

• If you are deep in debt, it might be better to delay participation.

Knowing your operation’s business model is an excellent practice in general. 

Make a plan to address any issues, and try to implement it on a small scale. 

If your patient base is incompatible and you face high competition, PM-JAY may not be the right option for you.

#2. Certifications & Incentives

Certifications:

• An entry-level National Accreditation Board for Hospitals & Healthcare Providers(NABH) certification = 10% incentive on package rates.

• Full NABH or National Quality Assurance Standards (NQAS) = +15%

• PM-JAY quality certifications: Bronze, Silver, Gold = +5%, +10%, +15%

Other Incentives:

• EHCPs in “aspirational districts” = +10%

• Educational EHCPs offering PG/DNB courses = +10%

In theory, a hospital can have a full NABH/NQAS/PM-JAY Gold certification (+15%), in an aspirational district (+10%), and offer PG/DNB courses (+10%). They can then get reimbursed for treatments under PM-JAY at 35% above the official package rates.

#3. Do Local Research

Look at your state and city’s AB-PMJAY data and analyse it for insights. Local health associations and NGOs can provide insights about your specific patient base/PM-JAY beneficiaries. Connect with other EHCPs to understand their plights.

• Guess the claim settlement ratio, outstanding debt, & average payment time.

• Are the beneficiaries familiar with the healthcare process under PM-JAY?

• What can you learn from other EHCPs in the area?

#4. Financial Testing

Don’t assume timely payments & record PM-JAY treatments as income after submitting the claims.

• Add all your fixed & rough variable expenses. 

• Factor in all your cash inflows, including the PM-JAY claims.

• Remove PM-JAY inflows for 3, 6, 9, & 12 months to see the gap vs expenses.

• Calculate the buffer, min. reserves/credit line, needed to survive each scenario.

If your accountant has a sense of humor, call this model Schrödinger’s reimbursement. 

This stress test allows management & owners to have a clear “go/no-go” signal. 

If unpaid claims pass a certain threshold, you must stop taking PM-JAY patients.

#5. Human Resources

People are the core of any organisation. The success of this scheme for your practice hinges on the coordination of two groups: Pradhan Mantri Arogya Mitras (PMAMs) & all staff involved in treating PM-JAY beneficiaries.

5.1 Arogyamitra:

A dedicated staff member to be the face of the scheme and responsible for its implementation. 

To be hired & trained by the private hospital itself.

• Quantity:

• The NAH recommends one arogyamitra for every 10 PM-JAY patients per day. 

• (eg, 30 daily PM-JAY patients = 3 PMAMs) 

• Selection criteria:

• Soft skills: local language fluency, empathetic, & amicable. 

• Hard skills: Scheme knowledge & computer proficiency.

• Education: 10+2 minimum.

• Role: 

• Greet patients, coordinate onboarding, staff, and discharge, & documentation.

• Managing the scheme’s IT platforms (BIS, TMS, & HEM).

• Training: the PMAM Qualification Pack (QP Code: HSS/Q6105)

Qualified female ASHA workers are often preferred for this role. SOPs are crucial as arogyamitras are the bedrock of this scheme. Make them responsible for updating the HEM & coordinating with other departments. 

5.2 Hospital Staff:

All staff members involved in treating beneficiaries should be informed of their role in the process. 

Workshops and educational modules are worth the effort to avoid claim issues.

• Everyone should be familiar with the general policy & implementation process.

• HMIS & EHR systems should be integrated with the PM-JAY IT ecosystem.

• Doctors should make detailed notes & suggest the right package.

• Staff should adhere to STGs & maintain good records.

• Clarify the “Whys” of participation to boost morale.

Avoid overburdening anyone, but encourage smoother claims & treatments. While many problems are unavoidable, effective solutions require collaboration between the admins and healers.

#6. Planning The Workflow

Ironing out the operational flow should be the next step. This entails mapping out your patients' physical movements and journey through the healthcare process. Each touch point should be placed accordingly.

• Strategic PMAM/AB-PMJAY desk placement at entry points for BIS verification.

• E.g., IBD, OBD, & Emergency reception areas

• Integrated IT systems throughout the hospital/clinic for pre-authorization.

• Detailed records aligned with STGs (as much as possible) at every step.

• Final check & smooth TMS/claim upload when the beneficiary is discharged.

#7. Monitoring & Improvement

The patient journey extends beyond your clinic, just as there is more to PM-JAY success than claim submission. 

Beneficiaries must be attracted, just as unpaid claims must be monitored & contingencies must be enforced.

• Consider marketing or awareness campaigns to guide & attract beneficiaries.

• Ensure that the financial stop-marks calculated in Step #4 are utilised. 

• E.g., Arogyamitras updates accountants on unpaid claims every month.

• Accounting tallies against projections & informs management.

• Monitor the PMAM satisfaction ratings submitted by beneficiaries.

• Hold regular workshops whenever possible to inform new staff.

#8. Systemic Reforms

We cannot pretend that Ayushman Bharat (PM-JAY) is flawless simply because it's ambitious. 

Real progress requires facing the facts, finding solutions, and breaking boundaries. 

The key to this is nurturing strong communities. 

Get involved with industry bodies, stay connected with other HCPs, and discuss issues. 

Support & participate in efforts to lobby the NHA & state governments for critical systemic reforms.

Potential Solutions

• Transparent, real-time, & verifiable claim tracking system visible to EHCPs.

• Penalty clause for delayed payments.

• For example, a 1% monthly interest charge on dues pending beyond the official timeline.

• Regularly improving STGs that may be outdated or problematic.

• Feedback & grievance redressal mechanisms on central, state, & district levels. 

Conclusion

Depending on your hospital/clinic’s location, following these practices can significantly improve your chances of thriving under PM-JAY. Otherwise, following the first few steps should tell you whether or not to join the scheme.

As a hospital owner, a senior doctor, or a clinic manager, it’s your responsibility to make your practice sustainable. This means having a solid ethical business plan and reliable financial models.

Healthcare providers, investors, and patients can achieve win-win scenarios. When health and wealth combine, it enhances our nation's quality of life. With better standards, everyone benefits.

FAQs

Q1. What is the main benefit for private hospitals to join AB-PMJAY?
Access to a larger patient base and government-backed reimbursements, provided claims are managed efficiently.

Q2. How can a hospital increase its PM-JAY reimbursement rates?
By achieving certifications like NABH/NQAS or PM-JAY Quality levels (Bronze, Silver, Gold), and leveraging incentives for aspirational districts or PG/DNB programs.

Q3. What is the biggest financial risk under PM-JAY?
Delayed reimbursements causing cash flow issues. That’s why stress-testing financial models & putting stop marks in place is critical.

Q4. Who manages the scheme inside the hospital?
Pradhan Mantri Arogya Mitras (PMAMs) act as the main coordinators, supported by doctors, nurses, and administrative staff.

Q5. What are common mistakes EHCPs should avoid?
Relying on timely reimbursements, poor documentation, ignoring STGs, and failing to train staff on scheme processes.