(a) whether complaints of fraud by private hospitals under the Pradhan Mantri Jan Arogya Yojana have come to the notice of the Government;
(b) if so, the details of fraud committed until nowand steps taken by the Ministry to investigate and curb the same;
(c) whether there are guidelines in place for private hospitals accepting and rejecting insurance claims under the scheme; and
(d) if so, the details thereof?
THE MINISTER OF STATE IN THE MINISTRY OF HEALTH AND
FAMILY WELFARE
(DR. BHARATI PRAVIN PAWAR)
(a) to (d):Ayushman Bharat –Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is governed on a zero tolerance approach to any kind of fraud viz. suspect/non-genuine medical treatment claims, impersonation and up-coding of treatment packages/procedures etc. National Health Authority -the implementing agency of AB-PMJAY has issued a comprehensive set of anti-fraud guidelines. Regular anti-fraud advisories are issued to States/UTs. National Anti-Fraud Unit (NAFU) is created at NHA for overall monitoring and implementation of anti-fraud framework supported by State Anti-Fraud Units (SAFUs) at State level. All claims require mandatory supporting documents along-with on-bed patient photo before approval and payment. The feature of Aadhar-based biometric verification of beneficiary at the time of admission and discharge is launched at all private hospitals. Use of artificial intelligence and machine learning is made for a comprehensive fraud analytics solution to detect fraud pro-actively, develop algorithms that can be used on large volume of data to identify suspect transactions and entities and risk scoring of hospitals and claims continuously.
As of 14th December, 2021, the anti-fraud measures taken by NHA and SHAs have resulted in the de-empanelment of 208 private healthcare providers. Penalties amounting to Rs. 16.80 crore are imposed against erring hospitals.
As per 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/trust, as per the case.The insurance company/trust settles these claims after verifying the genuineness thereof.