August 17, 2023: Recent media reports claiming that beneficiaries of the Ayushman Bharat Pradhan Mantri – Jan Arogya Yojana (AB PM-JAY) have been availing treatment despite being declared dead on the system are misleading and lack accurate information. These reports have been based on a misinterpretation of the findings of the Comptroller and Auditor General of India (CAG) regarding the performance audit on AB PM-JAY.
The CAG report, which covered the period from September 2018 to March 2021, was presented in the Monsoon Session of 2023. It highlighted certain instances where treatments were booked for beneficiaries who were declared deceased on the system. However, these instances do not indicate fraudulent activities but rather reveal nuances of the system’s functioning.
Under AB PM-JAY, hospitals are permitted to initiate a pre-authorization request for treatment up to three days before the admission date. This provision is aimed at ensuring that treatment is not denied due to limited connectivity or emergency situations. In some cases, beneficiaries were admitted, and treatment began before the pre-authorization request was raised. Unfortunately, these beneficiaries passed away during treatment, leading to their status being marked as deceased, often on the same admission date or earlier. It’s important to note that the same hospitals that initiated pre-authorization also reported these deaths on the system.
More than half of the cases highlighted in the report are attributed to public hospitals, which have no incentive to commit fraud as reimbursement is directly credited to their accounts. In the event of a beneficiary’s death during treatment, hospitals are obligated to submit a mandatory mortality report, further debunking any fraudulent intentions.
The report also mentioned cases where patients initially availed treatment as self-paid (private) patients but later discovered their eligibility under the AB PM-JAY scheme. These patients then requested retroactive pre-authorization to alleviate their financial burden.
Regarding instances where the same patient received treatment at two hospitals simultaneously, the AB PM-JAY allows children under 5 years of age to be treated using their parents’ Ayushman Cards. This leads to scenarios where a mother and her baby may be treated at different hospitals using the same card, or a father and a baby receive treatment on the father’s card.
It’s important to highlight that the AB PM-JAY features a rigorous four-step claim processing system that examines hospital claims at various stages. Any suspicious claims are subjected to further scrutiny through desk and field audits. Penalties, including de-empanelment, are enforced against erring hospitals.
The issue of multiple beneficiaries associated with a single mobile number holds no operational or financial implications. The AB PM-JAY’s beneficiary identification process relies on Aadhaar verification, and mobile numbers are captured for communication purposes only.
In response to the CAG’s recommendations, the National Health Authority and the Ministry of Health & Family Welfare are actively working on enhancing the system’s efficiency and robustness by strengthening IT platforms and processes. The AB PM-JAY remains committed to providing essential healthcare services to the deserving beneficiaries, safeguarding their well-being.
