Non-genuine hospital transactions were detected in the Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)
- According to the Health Ministry, 144 hospitals were fined and de-empanelled from the scheme based on confirmed fraudulent behaviour
- The Ministry added that the National Health Authority (NHA)—the implementing agency of AB-PMJAY—had issued a comprehensive set of anti-fraud guidelines to detect such beneficiaries
- It is a Centrally Sponsored Scheme having a central sector component under Ayushman Bharat Mission anchored in the Ministry of Health and Family Welfare (MoHFW).
- It is an umbrella of two major health initiatives, namely Health and wellness Centres and National Health Protection Scheme.
Health and Wellness Centres
- Under this 1.5 lakh existing sub centres will bring the health care system closer to the homes of people in the form of Health and wellness centres.
- These centres will provide comprehensive health care, including for non-communicable diseases and maternal and child health services.
National Health Protection Mission (AB-PMJAY)
- It provides a defined benefit cover of Rs. 5 lakh per family per year.
- This cover will take care of almost all secondary care and most of tertiary care procedures.
- To ensure that nobody is left out (especially women, children and elderly) there will be no cap on family size and age in the scheme.
- The benefit cover will also include pre and post-hospitalisation expenses.
- A defined transport allowance per hospitalisation will also be paid to the beneficiary.
- Benefits of the scheme are portable across the country and a beneficiary covered under the scheme will be allowed to take cashless benefits from any public/private empanelled hospitals across the country.
- The beneficiaries can avail benefits in both public and empanelled private facilities.
- To control costs, the payments for treatment will be done on a package rate (to be defined by the Government in advance) basis.
- The package rates will include all the costs associated with treatment. For beneficiaries, it will be a cashless, paperless transaction.
- At the national level to manage, a National Health Agency has been set up.
- States/ UTs are advised to implement the scheme by a dedicated entity called State Health Agency (SHA)
Steps taken to detect fraudulent beneficiaries
- Advisories: anti-fraud advisories were issued to States/UTs.
- National Anti-Fraud Unit (NAFU): it was created at the NHA for overall monitoring and implementation of anti-fraud framework supported by State Anti-Fraud Units at the State level.
- All claims required mandatory supporting documents alongwith on-bed patient photo before approval and payment.
- Aadhar-based biometric verification of beneficiary: this feature was launched at all private hospitals to be used at the time of admission and discharge
- Use of artificial intelligence and machine learning: it is made for a comprehensive fraud analytics solution to detect fraud proactively, develop algorithms that can be used on large volumes of data to identify suspect transactions and entities and risk scoring of hospitals and claims
- Punishment: suitable penal action in terms of anti-fraud guidelines was taken against hospitals that were found involved in fraud.
- National Health Agency