Ayushman Bharat: 4 hospitals get notices for co-payment

Over 300 hospitals have been served show-cause notices pan-India and de-empanelled, and penalties of over Rs 3 crore have been levied on them for submitting forged claims under the Ayushman Bharat health insurance scheme, a submission by the union government in the recent session of Parliament said.

While no hospital from Karnataka is in this list according to the state implementing agency —Suvarna Arogya Suraksha Trust (SAST), four hospitals have been served with notices for co-payment, that is, collecting money from patients despite getting reimbursement under Ayushman Bharat-Arogya Karnataka (AB-ArK).

Robust pre-authorisation

N T Abroo, Executive Director, SAST, told DH that since the state’s pre-authorisation mechanism was robust, no Karnataka hospital was there in the National Health Authority’s (NHA) hospital de-empanelment list. NHA is the apex body for implementing Ayushman Bharat. Since AB-ArK was rolled out in October last year, three private hospitals and one government hospital have been sent notices for co-payment. These hospitals are located in Bengaluru, Dharwad, Solapur and Manipal. The penalties range from Rs 30,000 to Rs 4.4 lakh.

“SAST does the pre-authorisation that is foolproof. So no false claims can be made. There is a specific amount that is pre-authorised for every procedure so the claims can’t exceed that amount. The system will flag it. There is not much fraud in Karnataka, but there is co-payment,” Abroo told DH.

She added that despite treatment being free for below poverty line patients, SAST gets complaints from patients that they were asked advance by hospitals and were promised a refund that they never got.

“Hospitals get approval from us and also take money from the patients. We get to know from feedback forms and calls made routinely from our call centre to the patients. Our Arogya Mitras also report such instances to us. When we send notices to hospitals, they generally agree,” she said.

The penalty is three times the amount collected from the patient, of which one portion is returned to the patient and two portions are kept with SAST. For a second offence, the penalty is five times the amount. For a third offence, it is suspension and subsequent violations, it is de-empanelment, said Abroo.

SAST generally authorises only five-day hospital stay and any extension has to be approved by them. SAST Chief Vigilance Officer Srinivas A V said that if the hospitals do not give satisfactory explanations and also do not pay up the penalties, SAST deducts the amount from subsequent claims made by the hospitals.