PMJAY Fraud: Gujarat to introduce new SOPs for private hospitals

With a significant resource allocated for implementing PM-JAY in Gujarat, there will be a digitalization initiative undertaken by the SHA (State Health Agency) to increase transparency and efficiency. Drawing inspiration from the Delhi Health Department, the SHA plans to develop an artificial intelligence-enabled portal designed to quickly identify fake or non-compliant documents, reports The Federal.

As part of the new measures, which will include a Standard Operating Procedure (SOP) for private hospitals linked to the PM-JAY scheme, the details were shared during a meeting held in Gandhinagar with Health Minister Rushikesh Patel and top officials. The four departments including cardiology, oncology, paediatrics, and orthopaedic surgery are considered the most misused categories as they allow the maximum amount of insurance under the PMJAY-MA scheme. The State Health Agency data shows the most common operations performed under the scheme are knee replacements and cardiac procedures — also the most susceptible to fraudulent claims. A two-tier scrutiny mechanism will be put in place under the new SOP.

“While the Union government gives up to Rs 5 lakh for cases in these specialities, the Gujarat government assures an additional amount up to Rs 10 lakh under the Maa Amrutam Yojna,” he said. “We have identified the loopholes in the current system, which will be replaced with a strict SOP to ensure that provisions of PMJAY are not misused,” Patel said.

Once a doctor recommends surgery, a small group of SHA doctors will review the recommendation before final approval. TBCs (Tumor Board Certificates) for oncology will also be mandated with an online portal to facilitate this process. To enhance oversight further, the SHA will require all hospitals that are empaneled under the scheme to use the Clinical Establishment Act. The formation of State Anti-Fraud Units (SAFU) will facilitate surprise inspections by dev teams at the district and state levels during the entire year.

Since the scheme was launched 5 years ago, the SHA has been manually managing the PM-JAY operations and monitoring over 36 crore Ayushman cards and as many as nearly 7 crore hospital admissions. But after the recent deaths of two patients at Khyati Multi Specialty Hospital, a thorough investigation was launched. Already, the licenses of 12 doctors named in these fraudulent activities were canceled by the Gujarat Medical Council.

Four hospitals, including Krishna Surgical Hospital and Swastik Multispeciality Hospitals, have been debarred from the PM-JAY scheme so far as part of the action, taking the total number of penalized hospitals to 16. Investigations are ongoing, with the Crime Branch also involved in the probe.