3.56 lakh claims worth Rs 643 cr rejected for frauds under Ayushman Bharat scheme

New Delhi: The Centre has rejected 3.56 lakh claims worth Rs 643 crore and removed 1,114 hospitals from the Ayushman Bharat panel to keep the government-funded family insurance scheme free of fraudulent activities, the Union Health Ministry informed the Parliament on Tuesday.

Moreover, penalties worth Rs 122 crore were levied on 1,504 errant hospitals whereas 549 hospitals were suspended following reports of frauds from the states and union territories, the Union Minister of State for Health Prataprao Jadhav told the Rajya Sabha.

The disclosure comes months after Gujarat police reported busting of a nationwide fraud on Ayushman Bharat cards.

Jadhav said a robust anti-fraud mechanism has been put in place and national anti-fraud unit has been set up with the primary responsibility for prevention, detection and deterrence of misuse and abuse under AB-PMJAY.

The scheme is in operation in 34 states with Odisha being the latest entrant. The new BJP government in Delhi has also decided joining the central scheme after the previous AAP-led government refused to be a part of it.

West Bengal is the only state, which is not a part of the scheme.

Currently, as many as 31,811 hospitals including 14,402 private ones are part of the Ayushman Bharat programme that supports hospitalisation of people from “economically vulnerable bottom 40% of India’s population.”

Under the scheme, the government provides health cover of Rs 5 lakh per family per year for secondary and tertiary care hospitalization to approximately 55 crore beneficiaries, corresponding to 12.37 crore families.

Recently, it has been expanded to cover six crore senior citizens of 70 years and above belonging to 4.5 crore families irrespective of their socioeconomic status.

Jadhav said triggers had been put in place in the transaction management system related to the uploading of the health benefit packages; OPD to IPD conversion and ghost billing or treatment not rendered but claims raised.

Checks are also in place for 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 mitigate the issues of duplicate registration and fraudulent claims.

“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,” the minister said.