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| Private hospitals under scanner for Rs 11.82 cr fraud | | J&K Ayushman Bharat Scheme | |
Early Times Report
Jammu, Feb 11: Private hospitals across the country are involved in making money through fraudulent means by presenting fake bills under the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) which was launched for the economically weaker sections of society.
Private hospitals in Jammu and Kashmir too have followed the footsteps of their counterparts in other parts of the country and have committed alleged fraud worth Rs 11.82 crore by presenting fake and fraudulent bills under this scheme.
Replying to a question in Rajya Sabha, Minister of State for Health and Family Welfare Pratap Rao Jadhav said that as many as 2. 7 lakh fake claims worth Rs 562. 4 crores made by private hospitals, were detected by the authorities. Out of these frauds, Rs 11.82 crore fraud detected in Jammu and Kashmir.
After detecting these frauds, a total of 1,114 hospitals have been de-empanelled, and 549 hospitals have been suspended under AB-PMJAY.
“AB-PMJAY is governed by a zero-tolerance approach towards any kind of fraud and abuse and various steps are taken for the prevention, detection, and deterrence of different kinds of fraud that could occur in the scheme at different stages of its implementation”, the Minister said, adding, “National Anti-Fraud Unit (NAFU) has been established at National Health Authority (NHA) and works in close coordination with State Anti-Fraud Units (SAFU) to investigate and take joint action against issues related to fraud and abuse”
“Out of 6.66 crore claims processed by NAFU, 2.7 lakh claims of private hospitals worth Rs. 562.4 crore were found to be Private hospitals in J&K have allegedly committed a fraud worth Rs 11.82 crore by presenting fake and fraudulent bills.
AB-PMJAY is governed by a zero-tolerance approach towards any kind of fraud and abuse.
National Anti-Fraud Unit (NAFU) has been established at National Health Authority (NHA) and works in close coordination with State Anti-Fraud Units (SAFU).
NHA has issued guidelines to undertake several punitive actions to curb cases involving misuse or abuse under AB-PMJAY.
NHA has issued guidelines to undertake several punitive actions to curb cases involving misuse or abuse under AB-PMJAY.
“These include the suspension or blacklisting or de empanelment of hospitals concerned from the AB-PMJAY network”, the Minister said, adding, “Additionally, misuse/abuse claims are rejected, and penalties or legal actions are imposed on such hospitals”.
To enhance the detection of misuse or abuse, near real-time monitoring and AI-based systems are used to check hospital claims. Furthermore, hospitals undergo random audits and surprise inspections to ensure the authenticity of claims. State Health Agencies (SHAs) also conduct regular desk medical audits as well as field audits.
“As a result of the stringent measures, a total of 1,114 hospitals have been de-empanelled, and 549 hospitals have been suspended under AB-PMJAY”, the Minister said, adding, “NAFU deployed 57 different technologies including rule-based triggers and Machine Learning algorithms, fuzzy logic, image classification, and de-duplication, etc. to identify misuse/abuse cases”.
Other technologies and interventions such as enhanced access controls to the NHAIT system, near real-time dashboards to highlight suspicious cases, regular monitoring and cleansing of databases, and other data analytic techniques are also deployed to make AB-PMJAY. |
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