Rs 562.4 crore fake claims under AB-PMJAY: 1,114 Hospitals de-empanelled, 549 suspended
New Delhi: According to the National Anti-Fraud Unit (NAFU) investigation, out of Rs 6.66 crore claims processed under the Ayushman Bharat-PM Jan Arogya Yojana (AB-PMJAY), nearly 2.7 lakh claims from private hospitals were found to be fraudulent. These claims, worth Rs 562.4 crore, involved alleged misuse, abuse, or incorrect entries. As a result, the government has de-empanelled 1,114 hospitals and suspended 549 hospitals under the scheme so far in this regard, Union Minister of State for Health Prataprao Jadhav informed the Rajya Sabha on Tuesday.
To address and curb such fraudulent activities, the government has introduced AI-based monitoring and real-time tracking systems. If any hospital is suspected of fake billing, the National Anti-Fraud Unit (NAFU) will closely scrutinise the claims and, place them on hold until proper verification is done, the Minister added.
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Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is a flagship scheme of the Government that provides health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization to approximately 55 crore beneficiaries corresponding to 12.37 crore families constituting economically vulnerable bottom 40% of India’s population.
Recently, the scheme has been expanded to cover 6 crore senior citizens of age 70 years and above belonging to 4.5 crore families irrespective of their socio-economic status under ABPMJAY with Vay Vandana Card.
The government has made it clear that AB-PMJAY is governed by a zero-tolerance approach towards any kind of fraud and abuse and various steps are taken for the prevention, detection and deterrence of different kinds of fraud that could occur in the scheme at different stages of its implementation. The National Anti-Fraud Unit (NAFU) has been established at the National Health Authority (NHA). It works in close coordination with State Anti-Fraud Units (SAFU) to investigate and take joint action against issues related to fraud and abuse.
The shocking discovery of the data was revealed by MoS Health while he was responding to a series of questions raised by Parliament member Shri A.D. Singh on February 11. He sought to whether there are instances of fake billing in Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) by private sector hospitals thereby making the poor people agree to their greed, if so, the details thereof, State-wise and hospital-wise, the action taken by Government on the hospitals claiming fake bills and the action Government is contemplating or has taken to make the AB-PMJAY foolproof to avoid leakage of public funds.
In response to these queries, Jadhav said, "Out of 6.66 crore claims processed by NAFU, 2.7 lakh claims of private hospitals worth Rs. 562.4 crore were found to be non-admissible on account of abuse, misuse or incorrect entries. Further, any claims by empanelled hospitals found to be suspicious by NAFU are withheld until proper scrutiny by SAFU teams including field verification where necessary."
He further mentioned that NHA has issued guidelines to undertake several punitive actions to curb cases involving misuse or abuse under AB-PMJAY. These include the suspension or blacklisting or de-empanelment of hospitals concerned from the AB-PMJAY network. Additionally, misuse/abuse claims are rejected, and penalties or legal actions are imposed on such hospitals. Near real-time monitoring and AI-based systems are used to check hospital claims to enhance the detection of misuse or abuse. Furthermore, hospitals undergo random audits and surprise inspections to ensure the authenticity of claims. State Health Agencies (SHAs) also conduct regular desk medical audits as well as field audits.
While responding to the question regarding the action taken by the government on the hospitals claiming fake bills, the Minister informed the Parliament that a total of 1,114 hospitals have been de-empanelled, and 549 hospitals have been suspended under AB-PMJAY as a result of the stringent measures.
"NAFU deployed 57 different technologies including rule-based triggers and Machine Learning algorithms, fuzzy logic, image classification and de-duplication, etc. to identify misuse/abuse cases. Other technologies and interventions such as enhanced access controls to NHA IT system, near real time dashboards to highlight suspicious cases, regular monitoring and cleansing of databases and other data analytic techniques are also deployed to make AB-PMJAY more foolproof," the Minister stated further.
