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| AB-PMJAY Under Scanner | | | The detection of Rs 562.4 crore worth of fraudulent claims under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), as revealed by Union Minister of State for Health and Family Welfare Pratap Rao Jadhav, highlights a concerning challenge in the country’s healthcare system.
The scale of the fraud, spanning private hospitals across the country, including Rs 11.82 crore in Jammu and Kashmir, calls for a robust response to ensure the integrity of this flagship scheme. The government’s action in de-empanelling 1,114 hospitals and suspending 549 others is a welcome step, but systemic reforms are essential to prevent such malpractice in the future.
AB-PMJAY, launched in 2018, aims to provide health insurance coverage of up to Rs 5 lakh per family per year to economically weaker sections. The scheme is designed to remove financial barriers to healthcare, yet fraudulent claims undermine its very purpose. The involvement of private hospitals in generating fake bills and siphoning off public funds is a serious breach of trust. This not only deprives deserving beneficiaries of treatment but also drains critical resources that could have been used to enhance healthcare infrastructure.
The detection of 2.7 lakh fake claims underscores the urgency of stricter regulatory mechanisms. Fraudulent hospitals manipulate the system through ghost patients, inflated bills, or unnecessary procedures, exploiting loopholes for financial gain.
The Rs 11.82 crore fraud in Jammu and Kashmir further points to the need for regional vigilance, given the challenges of ensuring healthcare access in such areas.
The de-empanelment of erring hospitals sends a strong message that malpractice will not be tolerated. This action should serve as a deterrent to institutions tempted to misuse the system. Additionally, suspending 549 hospitals and recovering fraudulent claims shows the government’s commitment to maintaining transparency. However, punitive action alone is not enough—there must be a long-term strategy to prevent such fraud from recurring.
The integration of AI-driven fraud detection tools within AB-PMJAY can help identify irregular patterns in billing and claims. Real-time monitoring and automated red-flagging of suspicious claims should be implemented across all states.
Periodic, independent audits of hospitals can ensure compliance with scheme guidelines. The government should also introduce third-party verification mechanisms to cross-check patient records, treatment history, and hospital claims.
Many patients may not be aware of fraudulent claims made in their names. Strengthening grievance redressal mechanisms and educating beneficiaries about their rights can prevent hospitals from exploiting them. A mobile-based feedback system could be introduced to verify whether a patient actually received the billed treatment.
While de-empanelment and suspension are necessary, stricter legal consequences, including financial penalties and criminal charges, should be imposed on repeat offenders. Holding hospital administrators accountable would serve as a deterrent against future fraud.
Despite these frauds, AB-PMJAY remains a transformative initiative in India’s healthcare landscape. Its success depends on ensuring that funds reach the right beneficiaries without leakage. The government’s recent crackdown should be followed by sustained vigilance, policy refinements, and stricter implementation. Only then can Ayushman Bharat fulfill its promise of accessible and affordable healthcare for all. |
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