'Dead' patients getting treatment: CAG audit report flags errors in PMJAY scheme, Health Ministry issues clarification

Emphasizing that the verification process for scheme beneficiaries does not rely on mobile numbers, the Health Ministry clarified in its official communication that the scheme solely employs mobile numbers for communication with beneficiaries in situations requiring assistance and to gather feedback regarding their treatment, with no intention of utilizing them for verification purposes.

The CAG's performance audit report, presented in the Lok Sabha on Monday, unveiled a series of instances within the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY) where medical treatment was administered to individuals who were previously recorded as deceased. Additionally, the report highlighted thousands of cases involving the utilization of identical Aadhaar numbers or inactive mobile phone numbers.

The CAG report pointed out that several beneficiaries were registered against the same mobile number under the health insurance scheme. It stated that 7.49 lakh people are registered against the mobile number 9999999999 as beneficiaries.

The audit stressed the importance of mobile numbers for beneficiary record retrieval and emphasized that loss of the e-card or beneficiary identification could lead to denials of scheme benefits.

Government's Response

However, Health Ministry sources told PTI that there is no role of mobile number in the verification process. The sources added that the mobile number has no role in deciding beneficiary eligibility and that it was an erroneous presumption that a beneficiary can avail treatment using their mobile number.

"The mobile number is captured only for the sake of reaching out to the beneficiaries in case of any need and for collecting feedback regarding the treatment provided," an official source told the news agency.

"Also, the fact that PM-JAY is an entitlement-based scheme and not an enrolment-based scheme and therefore, the beneficiary database is fixed and cannot be edited to add new beneficiaries. Thus, mobile number has no role in deciding beneficiary eligibility. Therefore, it is an erroneous presumption that beneficiary can avail treatment using mobile number," the source in the Health Ministry further said.

The Scheme

Implementation of the scheme is managed by the National Health Authority (NHA) at the Union level, and by state health authorities (SHAs) and district implementation units at the state level. The program's objective is to provide Rs 5 lakh per family based on strict eligibility criteria outlined in the scheme. The funding for this initiative is shared between state governments and the Union government, with a 60:40 ratio.

The NHA database indicates that 24.42 crore beneficiaries have been registered for the program, with Rs 67,456.21 crore expended on hospital admissions.

The CAG's assessment covers the period from September 2018 to March 2021, including the challenging times of the COVID-19 pandemic. Auditors scrutinized 964 hospitals across 161 districts in all 28 states and Union territories, with Delhi, Odisha, and West Bengal choosing not to participate in the scheme.

Remarkably, this marks the inaugural CAG report on PMJAY.

The Irregularities

The audit exposed widespread corruption in the settlement of insurance claims. It highlighted inadequate verification procedures by SHAs before approving claims for hospitals enlisted under the scheme. An alarming discovery was that 2.25 lakh cases presented surgery dates later than the discharge date, with Maharashtra alone accounting for over 1.79 lakh of these cases, amounting to more than Rs 300 crore in claimed expenses.

Further investigations revealed instances where hospitals submitted claims and SHAs disbursed funds even prior to the scheme's inception. In certain cases, adult patients received treatment under "pediatric specialty packages."

The audit report identified 45,846 claims where discharge dates preceded admission dates, and instances where the same patient was supposedly hospitalized simultaneously in multiple facilities.

Surprisingly, numerous claims persisted for individuals recorded as "deceased" in the database. Data from the Transaction Management System (TMS) disclosed 88,760 patient deaths during treatment, yet 2,14,923 claims were settled for "fresh treatments" given to these deceased patients, incurring an expenditure of nearly Rs 7 crore across 24 states and UTs. The highest prevalence of such cases was observed in Chhattisgarh, Haryana, Jharkhand, Kerala, and Madhya Pradesh.

Additionally, many beneficiary cards were invalidated due to fraudulent practices. However, the TMS, the established system, failed to prevent hospitals from making claims against these invalidated cards, resulting in Rs 71.47 lakh being disbursed to beneficiaries with such "disabled" cards.

Regarding the prevention of bogus beneficiaries, the NHA issued numerous alerts to SHAs to investigate 11.04 lakh suspicious cards. Regrettably, only 7.07 lakh cards were subjected to scrutiny. Gujarat, Madhya Pradesh, Meghalaya, and Uttar Pradesh recorded the highest numbers of fraudulent claims.

The report also cast doubts on the effectiveness of Aadhaar identification. Multiple registrations were found for a single Aadhaar card, and several registrations were linked to a small number of Aadhaar numbers in Tamil Nadu. This situation raises questions about the successful transmission of SMS notifications to verify eligibility, given the prevalence of duplicate numbers.

Another critical issue was the empanelment of hospitals without proper verification. According to the NHA database, 27,649 hospitals are empanelled for scheme services. However, physical verification reports in Bihar indicated that 16 of 23 Empaneled Healthcare Providers (EHCPs) failed to meet essential criteria. Similar discrepancies were found in other states.

Furthermore, several district empanelment committees approved hospital empanelment without sufficient checks or mandated inspections, resulting in the inclusion of 163 hospitals. The NHA attributed this to pandemic-related constraints preventing inspections.

The audit also identified hospitals failing to provide designated services after empanelment. In Maharashtra, for instance, 1,113 types of treatment facilities were unavailable in certain hospitals, requiring beneficiaries to travel to other districts for treatment.

Despite these challenges, the report underscores the need to invest in public hospitals to enhance the quality of health facilities, a central goal of the PMJAY. Inconsistencies in the ratio of EHCPs to beneficiaries were noted between states, highlighting disparities in healthcare access.

Malpractices were also uncovered among EHCPs. Hospitals in Assam offered non-empanelled specialties, and instances of cash demands from patients were found, contrary to the cashless treatment provisions.

Moreover, the report revealed inadequate supervision by SHAs, leading to excessive payments to hospitals in Andhra Pradesh, Madhya Pradesh, Punjab, and Tamil Nadu, totaling Rs 57.53 crore.

Finally, the audit criticized the NHA for insufficient oversight of SHAs and fund disbursement, even when they had not utilized their allocated shares. Despite these concerns, the health ministry's efforts to deploy artificial intelligence and machine learning to detect fraud demonstrate ongoing commitment to improving the scheme's integrity.

In conclusion, the report raises substantial concerns about the PMJAY, echoing previous warnings. These issues underscore the pressing need for comprehensive reforms to curb corruption and ensure the scheme's effective implementation.