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New Delhi: After attempts of fraud in the name of covid-19 treatment by hospitals empanelled under Ayushman Bharat—Pradhan Mantri Jan Arogya Yojna (AB-PMJAY) came to light, the government has warned of action against the erring hospitals.

The third-party administrators (TPA) servicing PMJAY have brought some incidents of fraud attempts to the notice of National Health Authority (NHA), the nodal agency responsible for implementing the AB-PMJAY. The testing and treatment for covid-19 was made available free of cost for Ayushman Bharat beneficiaries at private laboratories and empanelled hospitals in May. “We found one of the hospitals with more than 100 admissions for covid-19 alone. There's no way to verify the admission or presence of patients in the hospital as no one is allowed to visit dedicated covid-19 hospitals for audits. That being a testing centre also, positive cases can be created, and admissions, too, can be created," said one of the TPAs servicing PMJAY on condition of anonymity.

NHA, however, has said that it is governed by a zero-tolerance approach towards fraud and abuse, and in case malpractice is discovered, then the recovery of the money incurred in the treatment can be initiated from the concerned entity at any point of time. “In the current covid-19 situation, NHA is maintaining a fine balance between ensuring that no genuine beneficiary is denied treatment and that there is no fraud and abuse. Most of the covid testing and treatment under PMJAY is being provided by public hospitals and as such, misuse by empanelled hospitals or TPAs is out of question," said Indu Bhushan, CEO, AB-PMJAY, adding that government can even lodge FIRs against the hospitals, if they are found indulging in frauds. However, Bhushan did not rule out chances of some private hospitals admitting those covid-19 positive beneficiaries who do not require hospitalization, only to mint money.

NHA said that its National Anti-Fraud Unit (NAFU) monitors the utilization of all packages under AB-PMJAY to identify any suspect claims. While doing so, NAFU checks cases of excessive utilization as well as other triggers which include forensic and usage of advanced image analytics.

“These suspect cases are then shared with states to conduct further due diligence in the form of desk audit as well as beneficiary tele-audits in order to confirm the suspicion. In case any hospital is found to be engaging in any malpractice, the claims are rejected or the money is recovered retrospectively," said Bhushan.

Besides covid-19 treatment, the TPAs have highlighted some instances of attempts to mint money under the scheme. “We have got to know that hospitals send cashless request without a patient in the hospital. Hospitals will take ‘Golden card" (a paper card issued to beneficiary authenticating his eligibility to avail benefits under PMJAY) and send a cashless request to TPA," said Bharathi G., CEO of Family Health Plan Insurance TPA Pvt. Ltd (FHPL) that provides services as implementation support agency (ISA) in states where the scheme is run on trust model, such as Uttarakhand and Assam.

“As part of the document requirement, hospitals need to upload photograph of patient before and after the procedure. They manage photographs also in such a way that it is impossible to verify whether the patient and person in the ID card are same," she said.

Also, the insurance company appoints TPAs where the scheme is run on the insurance model such as Gujarat and Punjab. Primary services that FHPL provides in any state are cashless and claims management subset of these services are creating awareness among hospitals on using PMJAY software, fraud and abuse control, hospital and beneficiary audits and feedback, verification of beneficiary and confirming the identification in Beneficiary Identification System (BIS) for registration of beneficiaries in PMJAY software and contact centre management to address beneficiary queries and grievances.

“There have been instances where hospitals claim higher cost packages wrongly, such as using 2 stents and claiming for 3 in cardiac procedures; claiming expensive packages under paediatric NICU (neonatal intensive care unit) treatment etc. We have also come to know that expired medicines are being used by hospitals," said Bharathi G., adding that doing audits at hospitals during the admission period only can bring out these frauds.

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