The Centre’s ambitious healthcare insurance scheme — Pradhan Mantri Jan Arogya Yojana (PM-JAY) — under the National Health Authority (NHA) has noted that as per details provided by the States, more than 390 hospitals of the over 19,000 empanelled have been served show cause notices/suspended/de-empanelled across nine States for alleged fraud.
Of these, 171 hospitals have been de-empanelled. FIRs have been lodged against six hospitals in Uttarakhand and Jharkhand. The quantum of penalties levied on the listed hospitals is more than ₹4.6 crore.
“Close watch is also maintained on wrongful enrolment of beneficiaries; 3,785 Village Level Entrepreneurs (positioned at Common Service Centres) / Pradhan Mantri Arogya Mitras (positioned at PM-JAY empanelled hospitals) have been deactivated so far,” a senior NHA official said on Saturday.
The official confirmed that the National Anti-Fraud Unit (NAFU) at the National Health Authority (NHA) has detected the suspected fraud using the e-cards on basis of algorithms developed internally.
The cover provided under the PM-JAY health insurance scheme is ₹5 lakh per family.
Abuse-prone packages
“There are certain packages, especially abuse prone, 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 a unspecified package. There is no package under the PM-JAY scheme which is free for government hospitals,” added the official.
However, the NHA maintained that responsibility for closure action against fraudulent entities and fake cards lies with State health agencies which carry out their due diligence before initiating action.
Gujarat, Chhattisgarh, Madhya Pradesh and Punjab were among the States where frauds were detected in at different stages of the implementation of the PM-JAY.
Onus on States
“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,” the NHA official noted.
He added that suspicious cases being triggered by NAFU forensics team are regularly shared with the States for conducting medical audits.
“Number of triggered transactions shared with States so far amount to 0.25% of total admissions out of which 0.07% of total admissions have been confirmed as fraud so far. 0.58% cases of suspect e-cards have been sent to the States for investigation. Also almost all States have dedicated anti-fraud units now,” the official said.
