Five players in the data and analytics field have been shortlisted to detect frauds in the Pradhan Mantri Jan Arogya Yojana (PMJAY), popularly known as Ayushman Bharat. The companies — LexisNexis, Optum, Greenojo, MFX and SAS — will compete to detect malpractice by hospitals part of the scheme for six months. The best performer among the five will be taken on board as Ayushman Bharat’s official fraud and abuse detection firm.
Dr. Indu Bhushan, CEO of Ayushman Bharat, said, “These are major companies and among the best in the world. They have a lot of experience in detecting frauds and abuse of such schemes. For the first six months, the firms will be working free of cost. Once the best company is taken on board, their team will get outcome-based payment depending on the fraud they have detected.” Dr. Bhushan was speaking at Sankalp Global Summit in Goregaon on Wednesday.
Nearly 60% of procedures under Ayushman Bharat is being carried out in the private sector. At a time when the focus should be on strengthening public hospitals by improving infrastructure and getting better services, the ambitious government scheme has been criticised for directing public money into the private sector. There have also been many reports of a spurt in certain procedures in private hospitals, patients being charged for surgeries.
Dr. Bhushan said, “We have been carrying out selective audits. Packages that are prone to frauds have been restricted to public sector hospitals. For example, mental healthcare is restricted to public hospitals. There are certain procedures that require pre-authorisation from the States. We follow up with patients randomly to keep a check as well.”
Citing examples of their investigations, he said that a patient below 50 years who underwent cataract operation had triggered a follow-up call. A hospital was found to have carried out 77 cataract procedures in a single day, which triggered a team visit for investigation. A hysterectomy performed on a woman under 30 years also led to an inquiry.
The low package rates have kept the top private hospitals away from joining the scheme. Not a single plush hospital from Mumbai has got on board since the scheme was launched on September 23. Dr. Bhushan said efforts were on to approach the management of such hospitals. He said, “We are revising the package rates. Since they call the current rates bad, we don’t want to replace the ‘bad’ rates with another set of bad rates. The changes will be made after good research and methodology.”
While Maharashtra has failed to get top private hospitals on board, Tamil Nadu has managed to do so. Dr. Bhushan said, “We are looking at various reasons why some States have succeeded in this while some have not. Tamil Nadu, for example, has graded hospitals and the rates have been fixed according to the grade. We are considering if a similar model could work in other places as well.”
Published - December 13, 2018 12:41 am IST
