Some states used their own IT platform to process the claims and subsequently feed into transaction management system of PMJAY, which resulted in a possibility of overlap of beneficiaries of PMJAY with the beneficiaries of state specific schemes
Comptroller and Auditor General of India Audit Report on Union Government (Civil) – Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana administered by the National Health Authority (NHA) under the Ministry of Health and Family Welfare, covering the period from September 2018 to March 2021 was tabled in the Parliament recently.
The Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana aims to provide health cover of Rs five lakh per family per year for secondary and tertiary care hospitalisation to the poor and vulnerable section of the population, to improve affordability, accessibility, and quality of care for the poor and vulnerable section of the population.
A summary of key findings is provided as under:
❖ Beneficiary identification and registration
➢ As per NHA records, 7.87 crore beneficiary households were registered, constituting 73 per cent of the targeted households of 10.74 crore (November 2022).
➢ In the absence of adequate validation controls, errors were noticed in beneficiary database i.e. invalid names, unrealistic date of birth, duplicate PMJAY IDs, unrealistic size of family members in a household etc.
➢ Ineligible households were found registered as PMJAY beneficiaries and had availed the benefits ranging between Rs 0.12 lakh to Rs 22.44 crore under the Scheme.
❖ Hospital empanelment and management
➢ Some of the Empanelled Health Care Providers (EHCPs) neither fulfilled minimum criteria of support system and infrastructure nor conformed to the quality standards and criteria prescribed under the scheme guidelines.
➢ Beneficiaries in some states were charged for their treatment in empanelled EHCPs resulting in increase in out-of-pocket expenditure of beneficiaries.
❖ Claims management
➢ Some states used their own IT platform to process the claims and subsequently feed into transaction management system of PMJAY, which resulted in a possibility of overlap of beneficiaries of PMJAY with the beneficiaries of state specific schemes.
➢ In four states, excess payment of Rs 57.53 crore were made to the EHCPs.
➢ Payments were made in cases of death without obtaining death summary by State Health Authorities (SHA) and without receiving the mortality audit reports in several states.
➢ In eleven States/UTs, inadequate validation checks such as admission before preauthorisation, surgery after discharge of patient, payment prior to submission of claims, non-availability/invalid dates and other entries etc. were noted.
❖ Financial management
➢ NHA released grant amounting to Rs 185.60 crore to eight States without ensuring release of upfront shares by the respective States during 2018-19.
➢ NHA released excess grant to Andhra Pradesh (Rs 8.37 crore) and Mizoram (Rs 10.86 crore) without considering previous year’s balances and upfront shares.
➢ Seven SHAs diverted the grant of Rs 50.61 crore from one head to another head. In 20 SHAs, administrative grant of Rs 98.98 crore, Rs 128.13 crore and Rs 139.67 crore remained unspent at the close of 2018-19, 2019-20 and 2020-21 respectively. 10 SHAs did not remit interest of Rs 22.17 crore earned by them on unspent grants to NHA.
➢ Rs 458.19 crore was recoverable from the insurance companies in six States/UTs. The State of West Bengal withdrew from PMJAY in January 2019 but did not refund Rs 31.28 crore to NHA.
➢ The instructions of Government of India to track the expenditure flow through PFMS had not been fully complied with by NHA and SHAs. Monitoring and Grievance Redressal
➢ In five States/UTs, District Implementing Units (DIUs) had not been formed by SHA. In 22 States/UTs, shortage of manpower at various posts in SHAs and DIUs were noticed. In three States/UTs, State Grievance Redressal Committees (SGRCs) were constituted with delay up to approx. one year.
➢ Out of 37,903 grievances, only 3,718 complaints (9.80 per cent) were redressed within turnaround-time of 15 days and 33,100 complaints (87.33 per cent) redressed beyond turnaround-time. While 1,085 complaints were under process for redressal.
➢ Anti-Fraud Cell in four States/UTs, Claim Review Committees in eight States/UTs and Mortality and Morbidity Review Committees in 11 States/UT were not formed. In Assam and Jharkhand, 13 hospitals had indulged in mal-practices; however, no action was initiated against these hospital
Commenting on the report, Ankur Gigras, CEO & Co-Founder, HexaHealth said, “Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY), provides each household with a health insurance plan of Rs 5 Lac annually. The necessity for rigorous beneficiary verification has been highlighted by the recent CAG audit. Data collection at the industry level is essential, and an accurate Aadhaar-based e-KYC is essential for verifying beneficiaries. To find the gaps and close them, the data may be further divided into hospitals, illness conditions, and locations. Furthermore, advanced technologies like artificial intelligence (AI) and machine learning (ML) will make it easier to spot potentially fraudulent AB-PMJAY scheme transactions. These technologies serve the purpose of preventing, detecting, and deterring healthcare-related fraud.”
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