Ayushman Bharat Scheme: 3.56 Lakh Claims Worth Rs 643 Cr Rejected, 1,114 Hospitals Removed For Frauds

Union Minister of State for Health Prataprao Jadhav told the Rajya Sabha on Tuesday that suitable actions including rejection of 356,000 claims worth Rs 643 crore and de-empanelment of 1,114 hospitals have been taken against fraudulent entities as reported by the states and UTs under the Ayushman Bharat health insurance scheme.

He said in a written reply that 1,504 errant hospitals have been penalised Rs 122 crore and 549 hospitals have been suspended.

The Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is a flagship scheme of the government which provides health cover of Rs 5 lakh per family per year for secondary and tertiary care hospitalisation to approximately 550 million beneficiaries corresponding to 123.7 million families constituting economically vulnerable bottom 40 per cent of India's population.

On October 29, 2024, Prime Minister Shri Narendra Modi announced the expansion of AB-PMJAY to include all senior citizens aged 70 years and above. Under the expansion, all senior citizens aged 70 years and above are receiving an 'Ayushman Vay Vandana Card' which will help them avail healthcare benefits.

Ayushman Vay Vandana Card provides Rs 5 lakh free health cover to all senior citizens aged 70 years and above irrespective of their socio-economic status. The senior citizens belonging to families already covered under AB-PMJAY get an additional top-up cover up to Rs 5 lakh per year for themselves.

The scheme was expanded to cover six crore senior citizens belonging to 45 million families.

The AB-PMJAY is governed by a zero-tolerance policy towards misuse and abuse and various steps are taken for the prevention, detection and deterrence of different kinds of irregularities that could occur in the scheme at different stages of its implementation, Jadhav said.

A robust anti-fraud mechanism has been put in place and the National Anti-Fraud Unit (NAFU) has been set up with the primary responsibility for prevention, detection and deterrence of misuse and abuse under AB-PMJAY, Jadhav stated.

Under AB-PMJAY, triggers have been put in place in the Transaction Management System (TMS) related to the upcoming of the health benefit packages, OPD to IPD conversion, ghost billing or treatment not rendered but claims raised, duplicate images or documents used for multiple claims, forgery or concealment and beneficiary impersonation or counterfeiting so that automatic flags are raised for proper investigation of such suspected claims.

Further, beneficiaries are verified through Aadhaar e-KYC only at the time of the creation of the card and have to undergo Aadhaar authentication at the time of availing services, which helps in mitigating the issues of duplicate registration and fraudulent claims, Jadhav said.

To enhance the detection of misuse or abuse, near real-time monitoring and AI-based systems are used to check hospital claims. Further, hospitals undergo random audits and surprise inspections to ensure the authenticity of claims.

Under AB-PMJAY, a three-tier grievance redressal system has been put in place at the district, state and national levels with dedicated nodal officers and committees at each level. Beneficiaries can also file their grievance using different mediums including the web-based portal Centralised Grievance Redressal Management System (CGRMS), central and state call centres (14555), emails, letters to SHAs etc., Jadhav stated.