5 analytical firms look for fraud in Ayushman Bharat PMJAY

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PM Modi at inauguration event of PMJAY in Ranchi

Ayushman Bharat PMJAY is the first government scheme to start proactive fraud detection

If there’s a welfare scheme, there’s a fraud. And as the biggest government health insurance scheme in the world, Ayushman Bharat PMJAY is acutely aware of it.

That is why the National Health Agency – the implementing authority of Ayushman Bharat PMJAY (Pradhan Mantri Jan Arogya Yojana) has roped in five data analytical firms for proactive health scheme.

The analytics firms shortlisted from among 24 applicants who are currently giving their “proof of concept” performances are SAS, MFX, Optum, Lexis Nexis and GreenOjo.

This is the first time a health scheme in India is attempting to detect fraud proactively rather than tackling with them retroactively. Medicare and Medicaid – the health schemes in the United States though have a similar system.

The health ministry in fact, has just been hit by a hacking that cost it Rs 2.5 crore and the ministry’s Public Finance Management System has remained down for almost 25 days now, forcing it to resort to manual transactions.

AB-PMJAY, launched on September gives an annual health cover of Rs 5 lakh to 10.74 crore families.

The analytics firms shortlisted from among 24 applicants who are currently giving their “proof of concept” performances are SAS, MFX, Optum, Lexis Nexis and GreenOjo.

This is in effect next generation fraud detection in a health scheme anywhere in India. Under the Mukhyamatri Amrutam scheme of Gujarat, district coordinators undertake random surprise checks for physical verifications. In Maharashtra, under the Mahatma Jyotiba Phule Jan Arogya Yojana, the empanelment process is online to prevent fraud and there is mandatory pre-authorisation for all procedures.In the Chief Minister’s Comprehensive Health Insurance Scheme of Tamil Nadu, fraud prevention efforts revolve around multi level audits and patient feedback mechanism.

Internationally countries like Indonesia, Croatia, Turkey and USA not just define frauds but also use standard treatment guidelines  and audits to keep a check.

Profile of companies engaged by NHA

* SAS Institute has over 40 years of experience in Analytics, Data Science and Machine Learning. SAS solutions are deployed across 83,000 business, government and University sites across 146 countries.

* LexisNexis Risk Solutions Private Ltd is a global company providing business research and risk management services. It processes over 30 M transactions around the globe every hour and has a collation of over 6 Petabytes from 10,000 + data sources. Its solutions are deployed across 18 of the top 20 Health Payers in US and more than 80% of Private Life Insurance Companies in India

* MFX is a niche service provider in systems integration, technology and business applications. It is a digital transformation partner for property and casualty (P&C) insurance industry across the globe. It has been  rated amongst the top 25 Insurtech companies in 2018 by CIOApplications.com. It is a fully owned subsidiary of Quess Corp Limited, a provider of business services with headquarters based in Bangalore.

* Optum  is a 100% HIPAA compliant Information and technology-enabled health services business of United Health Group , a Fortune 5 company. Optum manages more than 20 years of longitudinal claims records from over 180 M customers. In India, they have also developed India’s first ever Meta data and Data standards for Healthcare in collaboration with National Health Systems Resource Center.

* Greenojo is an Indian Analytics Startup with over 200+ Man-years of Experience in Technology Consulting, Delivery and Sales works with customers across USA, Europe, Middle East & India.