The Pradhan Mantri Jan Arogya Yojana (PMJAY), the Centre's healthcare insurance scheme under the National Health Authority (NHA) has noted that 390 hospitals have been served show-cause notice, suspended or de-empanelled across nine states for alleged fraud.
Out of these 390 hospitals, 171 have been delisted from the PMJAY scheme. According to a report in The Hindu, FIRs have been lodged against six hospitals in Uttarakhand and Jharkhand. These hospitals have been levied penalties of Rs 4.6 crore.
A senior NHA official told the daily they are also keeping a close watch on the wrongful enrolment of beneficiaries. It said that 3,785 Village Level Entrepreneurs and Pradhan Mantri Arogya Mitras have been deactivated so far. The official added that National Anti-Fraud Unit (NAFU) at the NHA has detected the suspected fraud that uses e-cards on the basis of algorithms developed internally.
The official said that there are certain insurance packages under the PMJAY scheme that are prone to abuse. Such packages are reserved for government hospitals. It was hence detected that private hospitals were performing these procedures reserved for government hospitals and "blocking/submitting the same under a different package name or as a unspecified package".
The NHA has said that closure, action against fraudulent entities and fake cards remain the responsibility of state health agencies that carry due diligence before taking any action.
"We have issued comprehensive set of anti-fraud guidelines from the time of launch of the scheme and as a safeguard, pre-authorisation is required for most packages. All the packages prone to fraud/abuse have been reserved for public hospitals and need mandatory pre-authorisation. All claims require mandatory supporting documents before approval and payment. Also we conduct regular monitoring of empanelled hospitals," said the official to the daily.
PM-JAY frauds were detected in Gujarat, Chhattisgarh, Madhya Pradesh and Punjab among other states.