Rs 11.8 crore frauds exposed in Govt’s free health insurance scheme

Srinagar, Mar 12: In a blatant violation of guidelines, government authorities have uncovered frauds amounting to Rs 11.8 crore committed by private hospitals in Jammu and Kashmir during the implementation of the Centre’s free health insurance scheme.

The disclosure of fraud and misuse comes on the heels of the State Health Agency (SHA) action suspending the empanelment of five hospitals for violating guidelines issued by the National Health Authority (NHA) last month.

The disclosure comes as part of a nationwide crackdown on irregularities in the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), which provides health coverage of Rs 5 lakh per family annually for secondary and tertiary care hospitalisation.

The scheme covers approximately 55 crore beneficiaries from 12.37 crore economically vulnerable families representing the bottom 40 percent of India’s population.

Recently, the scheme was expanded to include 6 crore senior citizens aged 70 years and above, belonging to 4.5 crore families, regardless of their socio-economic status.

These beneficiaries receive coverage under AB-PMJAY with Vay Vandana Cards.

“The NHA has adopted a zero-tolerance approach toward fraud and abuse. The National Anti-Fraud Unit (NAFU), working in coordination with State Anti-Fraud Units (SAFU), investigates and takes action against fraudulent practices. Out of 6.66 crore claims processed by NAFU, approximately 2.7 lakh claims from private hospitals worth Rs 562.4 crore nationwide were found to be non-admissible due to abuse, misuse, or incorrect entries,” reads a report of Union Health Ministry.

To combat such irregularities, the NHA has implemented punitive measures including suspension, blacklisting, or de-empanelment of hospitals from the AB-PMJAY network.

Additionally, fraudulent claims are rejected, and penalties or legal actions are imposed on offending hospitals.

“The authority has deployed advanced technological solutions, including 57 different technologies such as AI-based systems, rule-based triggers, machine learning algorithms, fuzzy logic, and image classification to identify misuse and abuse cases. Regular desk and field audits are also conducted by State Health Agencies to ensure the authenticity of claims,” an official said.

As a result of these stringent measures, a total of 1114 hospitals have been de-empanelled and 549 hospitals have been suspended under AB-PMJAY nationwide.