Over 1,100 hospitals de-empanelled for AB-PMJAY Fraud: Health Minister tells Lok Sabha

New Delhi: In a recent Lok Sabha session, the Union Health Minister, Shri Prataprao Jadhav, informed that a total of 1,114 hospitals have been de-emplanelled from the Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) scheme, 1,504 hospitals penalised Rs 122 crore and 549 hospitals have been suspended for their involvement in fraudulent activities under the scheme.

Jadhav also clarified that hospitals cannot deny treatment to eligible beneficiaries of the scheme as per the terms and conditions of empanelment. In case of denial of treatment by the empanelled hospital, beneficiaries can lodge grievances.

AB-PMJAY, a flagship scheme of the central government, was launched in 2018 to provide ₹500,000 annual cashless health insurance cover to eligible citizens for treatment in hospitals across the country.

"Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is governed by a zero-tolerance policy towards misuse and abuse, and various steps are taken for prevention, detection and deterrence of different kinds of irregularities that could occur in the scheme at different stages of its implementation. A robust anti-fraud mechanism has been put in place, and the National Anti-Fraud Unit (NAFU) has been set up with the primary responsibility for prevention, detection and deterrence of misuse and abuse under AB-PMJAY," Jadhav said in a written reply to the parliament.

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The Minister shared the infromation while responding to various questions raised by Shri Rakesh Rathor who sought to know whether fraudulent transactions under Pradhan Mantri Jan Aarogya Yojana (Ayushman Bharat Yojana) have increased in the recent years, if so, the number of cases of fraudulent transactions reported so far and the amount recovered from them, whether it is a fact that many listed private hospitals are denying treatment under Ayushman Bharat Yojana due to delay in disbursement of outstanding amount.

He was also asked whether there have been cases of death due to unnecessary surgeries performed by listed/unpanelled hospitals in the country, and if so, the details thereof; and the details of the action taken against such fraudulent activities under Ayushman Bharat Yojana?

In response to these questions, the Minister said, "Suitable actions, including de-empanelment of 1114 hospitals, levying penalty worth Rs. 122 crore on 1504 errant hospitals and suspension of 549 hospitals, have been taken against fraudulent entities as reported by the States/UTs. As per the terms and conditions of empanelment, hospitals cannot deny treatment to eligible beneficiaries of the scheme. In case of denial of treatment by the empanelled hospital, beneficiaries can lodge grievances."

Under AB-PMJAY, a three-tier grievance redressal system at the District, State and National level has been created to resolve the issues faced by beneficiaries in utilising healthcare services. At each level, there is a dedicated nodal officer and Grievance Redressal Committee to address the grievances.

Jadhav said that the beneficiaries can file their grievances using different mediums, including the web-based portal Centralised Grievance Redressal Management System (CGRMS), Central & State call centres (14555), email, letter to State Health Agencies (SHAs), etc. Based on the nature of the grievance, necessary action, including providing support to the beneficiaries in availing treatment under the scheme, is taken.

Regarding the claim settlements, the minister said that state health agencies are responsible for payments. Claims within the state must be cleared within 15 days, while those involving treatment outside the state (portability claims) must be settled within 30 days. The turnaround time for claim settlements has improved year after year, and regular review meetings are held to monitor progress.

"Settlement of claims is an ongoing process. Under AB-PMJAY, claims are settled by respective State Health Agencies (SHA). NHA has laid down guidelines for payment of claims to hospitals within 15 days of claims submission for the intra-state hospitals (hospitals located within the State) and within 30 days in case of portability claims (hospitals located outside the State). Claims are required to be settled within the timeline specified under the scheme. Notable improvements have been recorded in the overall average Turnaround Time (TAT) for claim settlements year on year. Regular review meetings are organized to take stock of the progress with regards to the claims. Further, capacity-building activities are organised for efficient claims settlement," he added.

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