Krishna
Founder, ShylCare
If your hospital is empanelled under Ayushman Bharat (PMJAY), MJPJAY, CGHS, or any state health scheme, you already know the drill: these patients are simultaneously the most important and the most operationally complex part of your practice.
Important because they represent volume. A hospital empanelled under PMJAY in Maharashtra or UP can see 30–40% of its IPD admissions come through the scheme. That's significant revenue.
Complex because the billing rules are completely different from your regular patients, the documentation requirements are stringent, claims get rejected at alarming rates, and the reimbursement timelines can stretch to months.
Most hospitals I've visited handle scheme patients with what I'd charitably call "parallel workflows" — a separate register, a separate person who knows the scheme portal, a folder full of printouts. It works until it doesn't, and it usually stops working around the 20th scheme patient in a month.
Rate caps that don't match your costs. PMJAY packages have fixed prices. A knee replacement is covered at ₹80,000 under the scheme. Your actual cost — implant, OT time, anaesthesia, room for 5 days, post-op care — might be ₹1,10,000. That ₹30,000 gap is real, and it means every scheme patient on that package is a loss unless you manage costs carefully.
The response shouldn't be to avoid scheme patients (the volume matters) or to cut corners on care (that's not why anyone got into medicine). The response is to know your numbers precisely — which packages are profitable, which are loss-leaders, and how to optimise costs for the ones in between.
Package-based billing vs. itemised billing. Your regular billing is itemised — every consultation, test, drug, procedure is a line item. Scheme billing is package-based — one code, one price, everything included. This means you need to run two billing modes simultaneously for the same hospital.
When a scheme patient needs a service that's outside their package, things get complicated. Can you bill it separately? Does the scheme cover it? Is it an "add-on" package or out-of-pocket? Getting this wrong means either the patient pays for something they shouldn't, or the hospital absorbs a cost it shouldn't.
Documentation requirements that are non-negotiable. PMJAY claims require specific documents: referral letter, pre-auth approval, discharge summary in a specific format, procedure notes, investigation reports. Miss one document and the claim is rejected. I've talked to hospitals where the claim rejection rate is 15–20%, and when you dig into why, it's almost always documentation gaps — not clinical issues, just missing paperwork.
For a hospital submitting 50 claims a month at an average package value of ₹30,000, a 15% rejection rate means ₹2.25 lakh in revenue stuck in limbo. Some of it comes back after re-submission. Some doesn't.
Pre-authorisation delays. Most schemes require pre-auth before an elective procedure. You submit the request, wait for approval, then proceed. In theory, this takes 24–48 hours. In practice, especially for higher-value packages, it can take longer. Meanwhile, the patient is admitted, occupying a bed, and you're providing care without confirmed payment.
Scheme identification at registration. The moment a patient is identified as a scheme beneficiary — ideally at registration, definitely before admission — the system should switch to scheme-specific workflows. Different billing mode, different documentation checklist, different approval requirements. This sounds obvious, but I've seen hospitals where scheme identification happens at discharge, and then billing has to redo everything.
Pre-auth workflow built into the system. Instead of the scheme coordinator logging into a separate portal, the pre-auth request should be trackable within your hospital system. Request submitted, pending, approved, rejected — with the reference number linked to the patient's admission. When the approval comes, it's recorded with the approved amount, which becomes the cap for billing.
Auto-switching to package billing. This is the one that saves the most time. When a scheme patient is admitted with an approved package, the billing mode should automatically switch. Instead of your team manually adding itemised charges and then trying to reconcile them with the package amount at discharge, the system knows: this patient is on PMJAY package X at ₹Y. All services rendered are tracked internally for your cost analysis, but the bill to the scheme is the package amount.
If additional services outside the package are needed, they're flagged for separate handling — either as an add-on package or as patient responsibility, depending on scheme rules.
Discharge documentation checklist. The claim won't get paid without proper documents. So the system should enforce a checklist before discharge: pre-auth approval number present? Discharge summary complete? Investigation reports attached? Procedure notes uploaded? If anything is missing, the discharge process flags it — not as a suggestion, but as a blocker. Yes, this feels bureaucratic. But a claim rejected for a missing discharge summary costs far more than the two minutes it takes to complete it.
Claim tracking and follow-up. After discharge, the claim enters a pipeline: submitted, under review, approved, payment received. Most hospitals lose track at "submitted" and only follow up when they notice the money hasn't come. A proper tracking system shows aging claims — submitted 30 days ago, no response — so someone can follow up before the claim falls into administrative limbo.
Here's an exercise I'd recommend for any hospital doing scheme work: for each PMJAY/MJPJAY package you handle, calculate your actual cost. Not the standard room rent and pharmacy charges, but the real cost — staff time, consumables, bed occupancy opportunity cost.
You'll find that some packages are profitable. A normal delivery at ₹9,000 package rate might cost you ₹6,000 — healthy margin. A cardiac stent procedure at ₹55,000 package rate might cost you ₹62,000 — net loss.
Knowing this doesn't mean you stop doing loss-making procedures. But it means you know exactly what your scheme work costs, and you can plan accordingly — cross-subsidise from profitable packages, optimise consumable costs, and make informed decisions about which additional empanelments to pursue.
The hospitals that do well with government schemes aren't the ones that treat scheme patients as a burden. They're the ones that treat scheme billing as a different workflow that requires its own discipline — and they build their systems to enforce that discipline automatically.
If any of this sounds familiar, we'd love to show you how ShylCare handles it. Book a demo.
We'll walk through your actual workflows — no generic demo, no slide deck.