New Delhi: Chhattisgarh accounts for the highest number of penal actions taken for fraudulent hospital transactions with regard to claims under the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana followed by Jharkhand and Uttarakhand, the government said on Friday. Penal action has been taken for 8,586 hospital transactions in Chhattisgarh, 3,767 in Jharkhand, 3,016 in Uttarakhand, 2,065 in Punjab, 503 in Madhya Pradesh, 159 in Kerala and 140 in Bihar, Minister of State for Health Bharati Pravin Pawar said in a reply to a written question in Lok Sabha.
The government has provided details of penal action taken in respect of hospital transactions in 16 states and union territories (UTs). To a question on whether the government has taken note of fraudulent transactions recorded at empanelled healthcare providers under the AB-PMJAY, Pawar said the scheme is governed on a zero-tolerance approach to any kind of fraud vis-a-vis suspect or non-genuine medical treatment claims, impersonation and up-coding of treatment packages or procedures, among others.
The National Health Authority, the implementing agency of the AB-PMJAY, has issued a comprehensive set of anti-fraud guidelines, and anti-fraud advisories are regularly issued to states and UTs, the minister said. The National Anti-Fraud Unit (NAFU) has been created at the NHA for overall monitoring and implementation of an anti-fraud framework supported by State Anti-Fraud Units (SAFUs), she said. Pawar said that all claims require mandatory supporting documents along-with on-bed patient photo before approval and payment.
Aadhaar-based biometric verification of a beneficiary at the time of admission and discharge has been launched at all private hospitals, according to the minister's reply. Use of artificial intelligence and machine learning has been made for comprehensive fraud analytic solutions to detect fraud pro-actively, and develop algorithms that can be used on large volume of data to identify suspect transactions and entities and risk scoring of hospitals and claims, the minister said. According to the terms and conditions of empanelment, hospitals cannot deny treatment to genuine beneficiaries of the scheme. Medical treatment claims are filed by private hospitals with insurance companies or trusts, as per the case. The insurance company or trust settles these claims after verifying the genuineness thereof, Pawar stated.
PTI
