The Comptroller and Auditor General of India (CAG) made scathing observations with regards to the Ayushman Bharat-Pradhan Mantri Jan Aarogya Yojana (AB-PMJAY) scheme in its recent report and mentioned that patients earlier shown as ‘died’ continued to avail treatment under the scheme. States that reported the maximum number of such cases are Chhattisgarh, Haryana, Jharkhand, Kerala and Madhya Pradesh.
“Data analysis of mortality cases in TMS revealed that 88,760 patients died during treatment specified under the Scheme. A total of 2,14,923 claims shown as paid in the system, related to fresh treatment in respect of these patients. Audit further noted that in 3,903 of above claims amounting to ₹ 6.97 crore pertaining to 3,446 patients were paid to hospitals,” the report said.
Further data analysis suggested that the same patient could get admission in multiple hospitals during the same period of hospitalisation. The report also noted that there was no mechanism to prevent any patient from getting admissions in different hospitals during the same period of hospitalisation.
The National Health Authority (NHA) had acknowledged the issue in July 2020. The NHA said these cases arise in scenarios where a baby is born in one hospital and shifted for neo-natal care in another hospital using the PMJAY ID of the mother. In stark opposition to the NHA’s explanation, further data analysis by CAG found out that 78,396 claims of 48,387 patients were initiated in the database wherein date of discharge of these patients for earlier treatment was later than admission date for another treatment of the same patient.
These patients included 23,670 male patients. Such cases were more prevalent in Chhattisgarh, Gujarat, Kerala, Madhya Pradesh and Punjab. “Successful payment of such claims further indicates lapses on part of state health agencies (SHAs) in processing the claims without even verifying the requisite checks therein,” the report noted.
The NHA, however, said in August last year that the issue was due to non-synchronisation of date and time of computer, cases of neo-natal babies, recording of pre-authorization after the date of admission.
The CAG report was tabled in the Parliament when MoS Health and Family Welfare SP Singh Baghel told the Rajya Sabha in a written reply that the government uses artificial intelligence (AI) and machine learning (ML) to detect suspicious transactions and potential frauds under the AB-PMJAY scheme.
Baghel said that these technologies are used for prevention, detection and deterrence of healthcare frauds. He added the technologies are helpful in ensuring appropriate treatment to eligible beneficiaries. The minister informed the Upper House that total 24.33 crore Ayushman Bharat cards have been created under the scheme as of August 1, 2023.
Other issues with the AB-PMJAY database
On the irregularities in the registration and validation of beneficiaries, the CAG report further highlighted glaring faults in the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) database. The report said that several beneficiaries have been registered against the same mobile number. Around 9.85 lakh people are registered against the number 3 whereas 7.49 lakh people are registered against the mobile number 9999999999 as beneficiaries under the PM-JAY scheme.
The other most used numbers for this purpose are 8888888888, 9000000000, 20, 1435, and 185397. “Data analysis of BIS database revealed that there were large numbers of beneficiaries registered against same or invalid mobile number. Overall 1119 to 7,49,820 beneficiaries were linked with a single mobile number in the BIS database,” the CAG report states.
It also flagged several other faults in the database such as invalid names, duplicate health IDs, invalid entries in gender fields, unrealistic family sizes and unrealistic dates of birth. The report states that in 36 cases, two registrations were made against 18 Aadhaar numbers and 4,761 registrations were made against seven Aadhaar numbers in Tamil Nadu.
Negligence in following Ayushman Bharat-Pradhan Mantri Jan Aarogya Yojana (AB-PMJAY) guidelines
The report furthermore stated that several empanelled health care providers (EHCPs) under the AB-PMJAY scheme did not adhere to the prescribed quality standards and criteria, which are key to the safety and well-being of the beneficiaries in care and minimum conditions for empanelment.
Some of these EHCPs had a shortage of doctors, infrastructure and equipment. Some of them neither fulfilled the minimum criteria of support system and infrastructure nor conformed to the quality standards and criteria prescribed under the PM-ABJAY guidelines.
EHCPs in several states and union territories did not fully adhere to mandatory criteria related to infrastructure, fire safety measures, bio-medical waste management, and pollution control and hospital registration certificate. In some other EHCPs, fire safety certificates expired before empanelment.
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