Healthcare Heist: Multi-Crore Fraud Found In Rajasthan Government Health Scheme

The Special Operation Group (SOG) in Rajasthan has busted a fraud within the Rajasthan Government Health Scheme (RGHS), a state-run public healthcare scheme. The scam, allegedly, caused financial loss worth crores to the state exchequer. SOG found the involvement of a coordinated network of medical professionals (doctors), and diagnostic centres. The irregularities were discovered during a broader probe into RGHS implementation.

The police have arrested one doctor (Dr Kamal Kumar Agrawal, associate professor of Orthopaedics, SK Hospital in Sikar) and a lab operator (Dr Banwari Lal, a private laboratory operator), according to the PTI. These individuals, according to officials, have manipulated the system by prescribing unnecessary and expensive diagnostic tests, such as MRI scans.

The investigation found that the accused had not examined the patients ever, but had raised the bills fraudulently. In many cases, patients have been prescribed the tests while such patients were entirely absent from the facility.  

Reportedly, the fake tests and fraudulent practices were carried out through a nexus of doctors and lab operators who generated fake prescriptions and forged diagnostic reports to claim reimbursement of the cost from the state government. As a modus operandi, fake tests were falsely billed. For instance, a standard MRI test was billed as a contrast MRI test, which is a more expensive test, to claim a higher value. In other cases, multiple reports were generated from a single test to enhance the gains.

Further, the date of the report was also altered to claim funds for a patient who hadn’t even visited the city (Sikar) on that day. And, in some cases, the referrals issued by private doctors were manipulated to make them look like they came from government doctors, so as to enable them to claim the reimbursement.  

Once a fake document report was ready, the accused would upload the fake documents directly to the RGHS portal to claim reimbursement.

According to the Additional Director General of Police (SOG) Vishal Bansal, the fraudulent practices have not only caused a significant financial loss but also affected the genuine and needy beneficiaries. While the SOG continues the probe to identify if more staff were involved, the state health department has initiated strict legal action against the accused to ensure accountability.