National Health Authority (NHA), the agency that administers prime minister Narendra Modi-led government's flagship Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) has de-empanelled 171 hospitals due to fraudulent practices. While 60 of them are from Maharashtra, 46 are from Uttar Pradesh. The other hospitals where such malpractices were detected by NHA's National Anti-Fraud Unit (NAFU) are in states such as Tamil Nadu (21), Jharkhand (21), Uttarakhand (19), and two each in Himachal Pradesh and Chhattisgarh. NHA has levied Rs 4.5 crore penalty on these hospitals for indulging in malpractices.
AB-PMJAY provides a cover of up to Rs 5 lakh per family per year, for secondary and tertiary care hospitalisation to over 10.74 crore vulnerable entitled families (approximately 50 crore beneficiaries). The services are cashless and paperless and cover 1,393 health benefit packages with defined rates. Over 19,000 hospitals and health care providers have been empanelled across the country to provide healthcare services as per these packages.
According to NHA, suspicious cases being triggered by NAFU forensics team are regularly shared with states for conducting medical audits. Number of triggered transactions shared with states so far amount to 0.25 per cent of total admissions out of which 0.07 per cent of total admissions have been confirmed as fraud so far, it stated.
The agency also points out that as per details provided by the states, more than 390 hospitals have been served show-cause notice/suspended/de-empanelled in different states. FIR has been lodged against 6 hospitals in Uttarakhand and Jharkhand. Close watch is also maintained on wrongful enrolment of beneficiary and 3,785 village level entrepreneurs (positioned at common service centres) / Pradhan Mantri Arogya Mitras (positioned at PMJAY empanelled hospital) have been deactivated so far, it clarified. Another area of focus is to check use of fake e-cards. "NAFU has proactively detected the suspect e-cards on basis of algorithms developed internally and shared with states for due diligence and action. There's no possibility of fake e-card being generated automatically by the system," it added.
The NAFU also tracks cases of private hospitals performing packages that are reserved for government hospitals. "There are certain packages, especially abuse prone packages, which are reserved for government hospitals by the state authorities. It was detected that private hospitals were performing these government reserved procedures and blocking/submitting the same under a different package name or as unspecified package. These were proactively detected by the system and further action was taken," an NHA statement said.
As part of its fraud prevention efforts, bio-authorisation has been made mandatory at the time of admission and discharge of the beneficiaries. Similarly, NHA BIS system is enabled with in-built alerts that are triggered when suspect added members in high numbers are detected. The process is Aadhaar-enabled and biometrically verified. Further, the transaction data is monitored on real time basis through a specific dashboard - RADAR and watch is maintained right up to district/hospital. Strengthening of state level anti-fraud units and use of artificial intelligence at the Central level are other measures.
As on December 5, 2019, 33 states and union territories implemented Ayushman Bharat PMJAY and have issued over 11,48,33,583 beneficiary cards. PMJAY has more than 19,000 hospitals empanelled where nearly 68,37,588 people have availed of treatments under Pradhan Mantri Jan Arogya Yojana.