Irregularities in Ayushman Bharat: Indore hospital loses empanelment, 4 others get show cause notice

Indore: In breach of the Memorandum of Understanding (MoU) with the National Health Agency under PMJAY-Ayushman Bharat, a private medical college and hospital in Indore has been suspended and four hospitals served a show-cause notice by the Madhya Pradesh State Health Agency (SHA) over a host of irregularities.

The State Health Agency issued the notices to four hospitals for unnecessarily admitting patients to the ICU, inflating the number of patients admitted and violating the Ayushman Bharat Scheme. 

The notices were served following an audit conducted at the hospitals by the SHA teams between March 4 and 6. Hospital-wise violations have been listed in a notice issued by the SHA.

Under Ayushman Bharat, a flagship health scheme of the Centre, the government provides health security cover to 10 crore families or 50 crore people across the country. Hundreds of private hospitals are empanelled under it to provide treatment to citizens and they claim the expenses from the government.

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Index Hospital

“Index Medical College, Hospital and Research Center Indore has been suspended from the scheme for not complying with the MoU (memorandum of understanding) made in the Ayushman Scheme and committing irregularities to get undue benefits of the scheme,” said the suspension order issued by Ayushman Bharat Niramayam, Madhya Pradesh, on Tuesday.

The audit team of the Madhya Pradesh health authority inspected Index hospital in the first week of this month and found serious lapses. Many mistakes were made to get unfair benefits under the scheme, said the release.

As a result of the action, the hospital will no longer be able to provide treatment under the scheme.

The hospital was found to be overcharging patients and was involved in ghost billing, which means that the hospital record showed more patients getting treatment, but in fact, the number was less. The hospital purposely increased the headcount of the patients. The hospital had claimed to have admitted 500 patients while the actual number was only 76, said the release.

In order to extract money from the patients, the hospital had purposely shifted the patients to ICU when they were in no need of such treatment. By doing this, the hospital gained money from the patients illegally. OPD patients were being converted to the in-patient department; no mandatory clinical records were maintained and the same photos and documents were used in multiple claims.

Commenting on this, Dr Suresh Bhadoria, Chairman Index Hospital, told TOI, “We have submitted a reply to the notice. It is not a big deal. The scheme implementation is going on as usual.”

The hospital’s reply to a notice over the alleged irregularities was not satisfactory and it did not submit any “requisite record” to the audit team of the state health authority, the release said.

Apart from not cooperating with the audit team, a mob also was gathered in front of the auditors to create an unpleasant atmosphere, the release added. 

Sri Aurobindo Institute of Medical Sciences

By not enrolling eligible Ayushman beneficiaries under the scheme and without taking their informed consent, the hospital converted them from cashless to cash payment beneficiaries.

Patients under the Ayushman scheme are supposed to get free treatments. However, the SHA audit team found that the hospital charged money from Ayushman patients for consumables and materials already covered under the scheme.

In response to this, Dr Vinod Bhandari, owner of the hospital, said, “The notice has been issued without knowing proper facts. I have submitted the reply to SHA, the health commissioner, in this regard. The SHA needs to pay Rs 42 crore pending with them.”

Anand Hospital

The audit team found that the hospital was admitting patients when not required and treating them in ICU when they could have been treated in a routine ward.

The hospital has no fire exit and fire NOC, Ayushman kiosk and Ayushman Mitra. In fact, they were charging money from the patients covered under the Ayushman scheme.

“We have submitted a reply to the SHA notice by mail. The hospital has been NABH accredited for four years. There are no irregularities in the implementation of the Ayushman scheme:” Dr Arun Chopra, Medical Director of the hospital.

Retina Speciality Hospital

The audit team found that the hospital does not have a bill registrar or a refund registrar. In fact, they neglected the patients by not giving them food.

The hospital had raised 184 pre-authorizations on the day of the audit, but only four patients were present there, while it has a bed strength of just 13.

“There is nothing like irregularities in providing treatment to patients under the scheme. SHA helps in interpreting guidelines and we have been doing the work under the scheme for years:” Dr Gautam Patidar, Centre Head of the hospital.

Gokuldas Hospital

The hospital was found charging money for pre-authorization periods from patients. The guidelines mandate that hospitals bear all expenses, including diagnostic and consulting, seven days prior to the pre-authorization of the patients.

The hospital also did not enroll patients under the Ayushman scheme and charged money for treatment under the scheme.

“We have submitted a reply to SHA. These are not major irregularities. The SHA hasn’t paid dues for the last six months. So, they come up with this audit:” Dr Sanjay Gokuldas, owner of the hospital.

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