Aiming to curb the frauds in the centre’s ambitious healthcare insurance scheme Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (PM-JAY), the National Health Authority has served showcase notices to more than 390 hospitals of the over 19,000 empanelled hospitals.
Of these, around 171 hospitals have been de-empanelled. FIR was lodged against six hospitals in Uttarkhand and Jharkhand. Apart from these, penalties of more than Rs 4.6 crores has been levied in 9 states.
The National Anti-Fraud unit at NHA has pointed out several cases of malpractices in the empanelled hospitals. A senior official of NHA said that a 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.
“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 an unspecified package. There is no package under the PM-JAY scheme which is free for government hospitals,” said the official.
NHA says that the responsibility of closure action against fraudulent entities and fake cards lies with state health agencies which carry out their due diligence before initiating action.
NHA official said that they had issued a 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 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”, he added.
The number of triggered transactions shared with states amounts to 0.25 per cent of total admissions out of which 0.07 per cent of total admissions were confirmed as a fraud. 0.58 per cent of cases of suspect ecards wee sent to the states for investigation.
Ayushman Bharat- PMJAY is the largest healthcare scheme which aims to cover over ten crores economically backward families by providing a health cover of over five lakhs.

Source: The Hindu, Outlook India, Medical Dialogues

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