A penalty amount of ₹9.5 crore has been recovered while 5.3 lakh Ayushman cards have been disabled and 210 hospitals de-empanelled based on information of fraud obtained through artificial intelligence and machine learning-based anti-fraud initiative protecting the world’s largest government-run insurance scheme Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), according to data with the Health Ministry viewed by The Hindu.
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Around 0.18% of the total authorised hospital admissions under the scheme have also been confirmed as fraud since its inception. Additionally, 188 hospitals have been suspended and a penalty of ₹20.17 crore levied across board as part of the anti-fraud drive.
“Besides routine checks, the use of AI is now made for a comprehensive fraud analytics solution to detect fraud proactively, develop algorithms that can be used on a large volume of data to identify suspect transactions and entities and risk scoring of hospitals and claims,” the Ministry noted.
Previously the National Health Authority (NHA) — the implementing agency of AB-PMJAY — issued a comprehensive set of anti-fraud guidelines.
“Anti-fraud advisories were also issued to States/UTs. National Anti-Fraud Unit (NAFU) was created at NHA for overall monitoring and implementation of anti-fraud framework supported by State Anti-Fraud Units (SAFUs) at State level,” said a senior Health Ministry official.
He added that the scheme is governed by a zero-tolerance approach to any kind of fraud viz. suspect/non-genuine medical treatment claims, impersonation, and up-coding of treatment packages/procedures etc.
“All claims require mandatory supporting documents along with on-bed patient photo before approval and payment,” noted the Ministry.
Additionally, the feature of Aadhar-based biometric verification of beneficiaries at the time of admission and discharge is also active at all private hospitals.
Besides fraud detection, the programme claims that it has addressed 99% of all registered grievances (3.93 lakh) till 4 July this year.
As per government data, AB-PMJAY has been implemented in 33 States and UT with 24 crore health cards being issued to date. The government is now pushing for Ayushman card saturation — where of the existing cards< 40% were created in the last financial year (2022-23) — deployment of health kiosks, timely settlement of claims, empanel and activate hospitals and increase scheme uptake.
Meanwhile, the Health Ministry is also working on the robust implementation of the Ayushman Bharat Digital Mission aimed at creating a national digital system that will ensure the security, confidentiality, and privacy of health-related personal information. The Pradhan Mantri-Ayushman Bharat Health infrastructure mission has a total financial outlay of ₹64,180 crore from 2021-22 to 2025-26 and the government is now working at developing and strengthening health and wellness centres, blocking public health units, expanding disease surveillance systems, and strengthen pandemic research will providing a multi-sector national institutions platform.
Published - July 15, 2023 02:53 pm IST
