3,000 ‘fraud’ Ayushman cases under scanner

NEW DELHI: More than 3,000 suspicious cases amounting to Rs 4.5 crore have been detected under the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY). These cases have been sent to the states for investigation.

According to information provided by the National Health Authority (NHA), which is the monitoring authority for the scheme, fraudulent claims worth Rs 2.29 crore have been recovered from the hospitals after audits.

As per information, as many as 338 hospitals all across the country have been issued show cause notices or suspended/de-empanelled till August 2019 by various state governments following detection of fraud cases.

Following the incidents coming to light, the NHA has decided to conduct proof of concept with partners who are experts in detecting fraud. About two dozen showed interest in participating in the process after which the NHA selected five companies to execute the proof of concept.

Now, the NHA is in the process of procuring a fraud control partner based on the learning. This fraud control partner will help the NHA in studying the patterns of fraud, who the perpetrators are and then device mechanisms to check it. “We are fully aware of the innumerable threats posed by unscrupulous entities and individuals to the people we serve and to the information held by us. Therefore, the NHA is using Artificial Intelligence (AI) and predictive analytics to identify problem areas and patterns of abuse before they become serious frauds,” an official of the NHA said.

Following such cases, the NHA has set up the National Anti-Fraud Unit (NAFU) for implementing the guidelines prepared by the NHA with the support of state level units. The key tasks carried out by the NAFU relate to capacity building, launch of Proof of Concept (POC) project for data analytics and commencing medical units in the states. “We have also issued anti-fraud advisory notes for operational level actions to be taken by the states in different areas, like beneficiary identification system, hospital monitoring and action against fraudulent entities,” he said.

The PMJAY scheme is the world’s largest fully-funded health insurance scheme. Launched in September 2018, the scheme aims at providing medical insurance to nearly 107.4 million poor families of the country identified as per the Socio-Economic Caste Census Survey-2011. As per information provided by the NHA, about 64.9 lakh patients have benefited from the scheme till 22 November, for which more than 6.67 crore e-cards have been issued. As many as 20,752 hospitals have been empanelled under the scheme so far out of which 50% are private ones.