Research on PM-JAY Hospital Reimbursement Gaps

1. What Stops Private Hospitals from Engaging with PMJAY/MJPJAY? (2025)

• Documentation gap: The process from empanelment preparation to claims submission demands substantial administrative capacity. Technical errors in documentation cause prolonged claim pendency.
• Pre-authorisation gap: TPAs must respond within 24 hours but frequently delay or reject requests; outright rejections force hospitals to re-submit. Delays also arose when patients failed to submit required documents in time.
• Claim submission gap: Delays in settlement range from 3 months to a year - far beyond the guideline of 30 working days. Claims often clear the approval stage but get stuck at account verification, leaving some hospitals with pending amounts of Rs. 20-30 million (USD ~$239,000-$358,000).
• Partial sanction and rejection: Three patterns are identified - partial sanction, outright rejection, and processing delay.

2. Experiences and Challenges in Accessing Hospitalization under PM-JAY (PLoS ONE)

• Package-discovery/blocking gap: Ayushman Mitras (AMs) must identify and block the correct treatment package in the PM-JAY IT system before pre-authorisation. The mean time taken by AMs for admission and pre-authorisation submission was 32 minutes in Gujarat vs. 75 minutes in Madhya Pradesh - showing wide capacity variation and risk of error.
• Pre-authorisation approval gap: Guidelines require insurer response within 6 hours; real-world delays exceeded this, especially in private hospitals in MP.
• Capacity-building for AMs is flagged as a key intervention needed to close the gap.

3. Navigating Financial Sustainability in India's Private Healthcare Under Ayushman Bharat (2025)

• Low reimbursement rates and delayed payment as the primary threats to private hospital sustainability.
• Increased operational burden from administrative complexity.
• Administrative obstacles (bureaucratic paperwork, claim processing inefficiencies) as barriers that must be resolved for private sector participation to continue.
• A growing risk of voluntary hospital opt-outs from the scheme if documentation and payment deficiencies are not corrected.

4. Financial Viability of Private Hospitals Under AB PM-JAY (2025)

5. A Critical Analysis of Ayushman Bharat (2023)

• Fraud, upcoding, and provision of unnecessary care - which are often the stated grounds for claim rejection or query, thus contributing to under-reimbursement.
• Lop-sided access and exclusion at the periphery - where documentation and IT gaps are worst.
• Calls for impact evaluation in every state to generate actionable feedback for the National Health Authority (NHA).

6. WHO Assessment of Trust vs. Insurance Models in PM-JAY (WHO IRIS)

• Claim rejection rates were higher in Trust states (4.8%) vs. Insurance states (2.3%), partly attributable to documentation and package-blocking errors at the pre-authorisation stage.
• In Meghalaya, errors were caught early by correcting documentation at pre-authorisation rather than claim stage - reducing downstream rejections.
• Hospitals frequently block the wrong package, or a package not admissible under PM-JAY, at pre-authorisation - a direct package-discovery gap.
• IT system issues, internet connectivity, and manpower constraints at ISAs/TPAs compound delays.

7. Cross-Sectional Study on Knowledge Gaps and Utilization (ResearchSquare preprint)

• Delay in claim processing was the most common challenge (41.7% of participants).
• Package unavailability within the hospital (22.9%) - a package-discovery gap.
• Issues with refund of pre-approval payments (12.5%).
• Biometric verification and Aadhaar linkage failures blocking claim initiation.

Summary Table of Gaps Covered

PM-JAY Reimbursement Gap — Research Papers & Links