Ayushman Bharat: Claims worth Rs 643 cr rejected for ‘frauds’
New Delhi: Union Minister of State for Health Prataprao Jadhav told the Rajya Sabha on Tuesday that suitable actions including rejection of 3.56 lakh claims worth Rs 643 crore and de-empanelment of 1,114 hospitals have been taken against fraudulent entities as reported by the states and UTs under the Ayushman Bharat health insurance scheme.
He said in a written reply that 1,504 errant hospitals have been penalised Rs 122 crore and 549 hospitals have been suspended.
The Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is a flagship scheme of the government which provides health cover of Rs 5 lakh per family per year for secondary and tertiary care hospitalisation to approximately 55 crore beneficiaries corresponding to 12.37 crore families constituting economically vulnerable bottom 40 per cent of India’s population.
On October 29, 2024, Prime Minister Narendra Modi announced expansion of AB-PMJAY to include all senior citizens aged 70 years and above. Under the expansion, all senior citizen aged 70 years and above are receiving ‘Ayushman Vay Vandana Card’ which will help them avail healthcare benefits.
Ayushman Vay Vandana Card provides Rs 5 lakh free health cover to all senior citizens aged 70 years and above irrespective of their socio-economic status. The senior citizens belonging to families already covered under AB-PMJAY get an additional top-up cover up to Rs 5 lakh per year for themselves. The scheme was expanded to cover six crore senior citizens belonging to 4.5 crore families.
The AB-PMJAY is governed by a zero-tolerance policy towards misuse and abuse and various steps are taken for the prevention, detection and deterrence of different kinds of irregularities that could occur in the scheme at different stages of its implementation, Jadhav said. A robust anti-fraud mechanism has been put in place and National Anti-Fraud Unit (NAFU) has been set up with the primary responsibility for prevention, detection and deterrence of misuse and abuse under AB-PMJAY, he added.
Under AB-PMJAY, triggers have been put in place in the Transaction Management System (TMS) related to the upcoding of the health benefit packages, OPD to IPD conversion, ghost billing, duplicate images or documents used for multiple claims and beneficiary impersonation so that automatic flags are raised for proper investigation.
