Non-genuine 18,606 hospital transactions were detected in the Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) with penalty amounting to ₹ 29.72 crore being levied on erring hospitals. Also 144 hospitals were de-empanelled from the scheme based on confirmed fraudulent behavior, said the Health Ministry in its reply to the Parliament in the recently concluded session.
The Ministry added that the National Health Authority (NHA)—the implementing agency of AB-PMJAY—had issued a comprehensive set of anti-fraud guidelines. The anti-fraud advisories were issued to States/UTs. National Anti-Fraud Unit (NAFU) was created at the NHA for overall monitoring and implementation of anti-fraud framework supported by State Anti-Fraud Units at the State level.
The Ministry further said that all claims required mandatory supporting documents alongwith on-bed patient photo before approval and payment.
The feature of Aadhar-based biometric verification of beneficiary at the time of admission and discharge was launched at all private hospitals.
``Use of artificial intelligence and machine learning is made for a comprehensive fraud analytics solution to detect fraud proactively, develop algorithms that can be used on large volumes of data to identify suspect transactions and entities and risk scoring of hospitals and claims,’’ said the Ministry.
It added that a suitable penal action in terms of anti-fraud guidelines was taken against hospitals that were found involved in fraud. The AB-PMJAY was governed on 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, said the Ministry.
