Ayushman Bharat, also known as the Pradhan Mantri Jan Arogya Yojana (PMJAY), is a flagship health insurance scheme launched by the Government of India. It aims to provide health coverage to economically vulnerable sections of society by offering financial protection against catastrophic health expenses.
The scheme primarily targets the poor, deprived rural families, and identified occupational categories of urban workers’ families. Under Ayushman Bharat, eligible beneficiaries receive health coverage of up to Rs. 5 lakh per family per year for secondary and tertiary care hospitalization.
One of the key components of Ayushman Bharat is the creation of Health and Wellness Centers (HWCs) to provide comprehensive primary healthcare services. These centers serve as the first point of contact for healthcare needs, offering a range of services from preventive to promotive healthcare.
Overall, Ayushman Bharat aims to make healthcare more accessible and affordable for millions of Indians, reducing the financial burden of healthcare expenses and improving health outcomes across the nation.
The Ayushman Bharat health insurance scheme has been a significant initiative to provide medical insurance to nearly 107.4 million poor families in India. However, like any large-scale program, there have been instances of fraud and misuse.
One unique ID: Several beneficiaries
One of the most glaring instances of corruption within the implementation of this scheme was uncovered in the registration and identification of beneficiaries.
As per the scheme’s guidelines, a unique PMJAY ID should be assigned to beneficiaries upon successful verification. However, the audit revealed a concerning revelation – 1.57 unique IDs were duplicated in the database, suggesting a serious flaw in the system. The report cautioned that such duplication raises the possibility of ineligible beneficiaries being present in the Beneficiary Identification System (BIS) database.
In addition to Aadhaar numbers, the scheme also relies on beneficiaries’ phone numbers for identification. The audit uncovered a significant number of beneficiaries registered under the same or invalid mobile numbers. For instance, an alarming 7.5 lakh beneficiaries were registered under the mobile number ‘9999999999’, with another 1.4 lakh under ‘8888888888’.
Following the release of the CAG report, an anonymous source from the Union health and family welfare ministry, as quoted by PTI, clarified that the scheme primarily used mobile numbers for communication purposes and to gather feedback on treatment, rather than for verification.
The unnamed official elaborated further, stating, “AB-PMJAY identifies the beneficiary through Aadhaar identification wherein the beneficiary undergoes the process of mandatory Aadhaar-based e-KYC. The details fetched from the Aadhaar database are matched with the source database, and accordingly, the request for Ayushman card is approved or rejected based on the beneficiary details.”
Hospital empanelment without checks
Hospital empanelment, a crucial aspect of the scheme’s implementation, has faced serious lapses and challenges, as revealed by audit findings.
According to the National Health Authority (NHA) database, a staggering 27,649 hospitals have been empanelled across India to provide services under the scheme. This includes both public facilities capable of providing inpatient services and private healthcare facilities. However, despite the extensive empanelment, issues have arisen regarding the fulfilment of essential criteria by Empaneled Healthcare Providers (EHCPs).
In Bihar and several other states such as Andaman and Nicobar Islands, Assam, Chandigarh, Gujarat, Himachal Pradesh, Jammu and Kashmir, Manipur, Nagaland, Puducherry, Tripura, and Uttar Pradesh, physical verification reports of EHCPs revealed significant deficiencies. Out of 23 EHCPs inspected in Bihar, 16 failed to meet essential criteria. Similar situations were observed in other states, where hospitals were empanelled without proper infrastructure and support systems such as medical equipment, operation theatres, ICU care with ventilator support, pharmacy, dialysis units, blood banks, and round-the-clock ambulance services.
Furthermore, auditors discovered instances where empanelment committees approved hospitals without conducting mandated physical inspections. In states like Tripura, Uttarakhand, and Manipur, 163 hospitals were empanelled without sufficient checks, with Tripura leading with 103 such instances. The NHA cited pandemic conditions as the reason for the inability to conduct inspections at these facilities.
Moreover, many empanelled hospitals failed to provide the fixed services they were enlisted for. For example, in Maharashtra, audit findings indicated that hospitals in certain districts did not offer 1,113 types of treatment facilities, compelling beneficiaries to seek treatment in other districts, causing inconvenience and additional financial burden.
This situation not only highlights the shortcomings in hospital empanelment and oversight but also undermines the primary objective of the PMJAY scheme to reduce out-of-pocket expenditure for beneficiaries. Addressing these issues is crucial to ensuring effective implementation and equitable access to quality healthcare services for all beneficiaries.
Missing Hospitals
The presence of hospitals on the empanelled list doesn’t guarantee their active participation in the scheme, let alone the quality of services provided. In Andhra Pradesh, for instance, half of the 1,421 empanelled EHCPs submitted zero claims, indicating a lack of provision of PMJAY services. Similarly, 81 EHCPs submitted only 0-5 claims, raising concerns about their engagement. This trend was observed in other states as well.
The NHA attributed this phenomenon to EHCPs’ reluctance to provide services to PMJAY beneficiaries due to the pandemic. However, the report did not specify the proportion of public versus private facilities exhibiting this reluctance.
Experts and health activists have long emphasized the urgent need to invest in public hospitals to enhance their quality and align them with the prescribed criteria of the PMJAY scheme.
Another challenge hindering scheme implementation is the inadequate ratio of EHCPs to beneficiaries. In Bihar, for instance, despite 100% eligible people being registered under the scheme, there are only 1.8 EHCPs per lakh population, compared to 26.6 in Goa.
Furthermore, EHCPs were found engaging in various malpractices. In Assam, 18 EHCPs provided treatments for non-empanelled specialities, resulting in total claims of Rs 1.27 crore. Despite the scheme’s mandate for cashless transactions, hospitals were found demanding money from patients for various services, leading to their de-empanelment in some cases.
In 11 states, 241 hospitals were de-empanelled from the PMJAY due to low performance and malpractices. However, this action didn’t always halt payments to these hospitals. For instance, despite Ananya Memorial Hospital in Bihar being suspended in August 2019, it received payments totaling Rs 67,900 between 2018 and 2020.
Poor supervision by the State Health Agencies (SHAs) has resulted in instances of excess payments to hospitals. The audit revealed that four states—Andhra Pradesh, Madhya Pradesh, Punjab, and Tamil Nadu—made excess payments amounting to Rs 57.53 crore.
Lastly, the auditors criticized the NHA for inadequate supervision over SHAs and for releasing funds to them even when they had not met their own spending obligations or when funds were lying unspent. Addressing these issues is essential to ensure effective implementation and accountability within the PMJAY scheme.
Other malpractices
The auditors uncovered widespread corruption in insurance claims settlement, highlighting serious lapses in validation procedures by the State Health Agencies (SHAs) before releasing funds to empanelled hospitals.
A staggering 2.25 lakh cases revealed discrepancies where the date of surgery was shown to be later than the date of discharge, indicating potential fraudulent practices. Maharashtra alone accounted for over 1.79 lakh such cases, amounting to claims totaling over Rs 300 crore.
Additionally, some hospitals submitted claims and received payments for dates preceding the scheme’s inception, while in other instances, funds were transferred to hospitals before claims were even submitted. Furthermore, patients above 18 years of age were erroneously treated under paediatric speciality packages.
The audit also unearthed alarming anomalies, including 45,846 cases where the date of discharge preceded the date of admission. Moreover, multiple instances were found where one patient was shown to be simultaneously hospitalized in multiple facilities.
Another concerning revelation was the submission of claims for individuals listed as “deceased” in the database. Despite data indicating 88,760 patient deaths during treatment, claims for fresh treatments were settled for 2,14,923 deceased patients, totaling almost Rs 7 crore across 24 states and union territories. The highest number of such cases occurred in Chhattisgarh, Haryana, Jharkhand, Kerala, and Madhya Pradesh.
Additionally, malpractices led to the cancellation of lakhs of beneficiary cards shortly after registration. However, the Transaction Management System (TMS) failed to restrict pre-authorization requests for claims against these cancelled cards, resulting in payments totaling Rs 71.47 lakh.
Despite alerts generated by the National Health Authority (NHA) cautioning against 11.04 lakh bogus beneficiaries, SHAs only investigated 7.07 lakh cards. Gujarat, Madhya Pradesh, Meghalaya, and Uttar Pradesh reported the highest number of fraudulent claims.
These findings underscore the urgent need for stringent oversight and reforms to prevent and address fraudulent activities within the scheme, ensuring that funds are used appropriately and beneficiaries receive the intended benefits.
