Governments tells Parliament 57 different technologies including rule-based triggers and machine learning algorithms used to detect fraud
Out of 6.66 crore claims made under the Pradhan Mantri Jan Arogya Yojana that were processed by the anti fraud unit, 2.7 lakh claims of private hospitals worth Rs. 562.4 crore were found to be non admissible, the government told Parliament Tuesday. The National Anti Fraud Unit (NAFU) rejected the claims on account of abuse, misuse or incorrect entries.
PMJAY is the tertiary care arm of Ayushman Bharat which is the flagship health programme of the NDA government. Under PMJAY, eligible families are entitled to an annual health cover of Rs 5 lakh. Families with members who are aged above 70 years are entitled to an additional Rs 5 lakh for every such member.
“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 deempanelment of hospitals concerned from the AB-PMJAY network. Additionally, misuse/abuse claims are rejected, and penalties or legal actions are imposed on such hospitals. To enhance detection of misuse or abuse, near real-time monitoring and AI-based systems are used to check the 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,” minister of state Prataprao Jadhav told the Rajya Sabha while replying to a question from RJD MP A D Singh.
There have been several reports of fraudulent claims by hospitals under PMJAY in recent months and some reports also of surgeries or medical procedures being performed in insured patients without any medical rationale for doing so, just so that the claims can be made.
“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 NHA IT 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 more foolproof,” Jadhav added in his written reply.
