Fraudulent transactions found in Ayushman Bharat, 144 Hospitals De-empanelled: MoS Health

New Delhi: There have been more than 18,000 fraudulent hospital transactions that were found in the insurance arm of Ayushman Bharat, the flagship health programme of the National Democratic Alliance (NDA) government from the time it was launched in 2018 as stated by the government in Rajya Sabha, reports the Print.  

The insurance scheme known as Pradhan Mantri Jan Arogya Yojana (PMJAY) was launched to provide health coverage of Rs 5 lakh per annum to eligible families. 

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Dr Bharati Pravin Pawar, minister of state for health and family welfare, in a written reply in Rajya Sabha stated, "Suitable penal action in terms of anti-fraud guidelines was taken against hospitals in respect of non-genuine 18,606 hospital transactions. Penalty amounting to Rs 29.72 crore was levied on erring hospitals. Further, 144 hospitals are                  de-empanelled from the scheme based on confirmed fraudulent behaviour."

PMJAY is a public-private partnership through which cardholders can get treatment at any empanelled hospital, government, or private. The procedures covered by the scheme have rates fixed in advance, and the beneficiaries are not required to make any payments up front, and when claims are raised, hospitals are reimbursed the entire amount, provided this doesn't exceed the prescribed rates.

The target population for PMJAY is nearly 50 crore people, who are identified using data from 2011 Socio-Economic and Caste Census, and the beneficiaries are covered by 1,500 treatment packages. 

Further, responding to a question by Trinamool Congress MP Jawhar Sircar, Dr. Pawar said that the Ayushman Bharat–Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is governed on a zero-tolerance approach to any kind of fraud. The practices seen as fraudulent under the scheme include suspect or non-genuine medical treatment claims, impersonation, and upcoding of treatment packages or procedures. 

Dr Pawar added, "National Health Authority — the implementing agency of AB-PMJAY — has issued a comprehensive set of anti-fraud guidelines. Anti-fraud advisories are issued to states/ UTs. National Anti-Fraud Unit (NAFU) is created at NHA for overall monitoring and implementation of anti-fraud framework supported by State Anti-Fraud Units (SAFUs) at state level."

As per the report in the Print, she said, "All claims require mandatory supporting documents along-with on-bed patient photo before approval and payment. The feature of Aadhaar-based biometric verification of [the] beneficiary at the time of admission and discharge is launched at all private hospitals. Use of artificial intelligence and machine learning is made for a comprehensive fraud analytics solution to detect fraud proactively, develop algorithms that can be used on [a] large volume of data to identify suspect transactions and entities, and risk scoring of hospitals and claims."

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