PRADHAN MANTRI JAN AROGYA YOJANA : SCHEME
NEWS: Over 3,200 PMJAY hospitals should be penalised for fraud, says NHA
WHAT’S IN THE NEWS?
The Pradhan Mantri Jan Arogya Yojana (PMJAY) is addressing healthcare access for 50 crore beneficiaries, but fraudulent activities in hospitals have led to penalties, suspensions, and calls for stronger regulation. The National Health Authority is implementing measures to tackle fraud and improve system integrity through technology and data-driven monitoring.
Fraudulent Activities in PMJAY
• 600 Hospitals Suspended: The Competition Commission of India (CCI) has imposed action on 600 hospitals under PMJAY for fraudulent activities. These hospitals were found to have engaged in practices such as overbilling or submitting false claims for services not rendered. This suspension is part of an ongoing effort to cleanse the system and ensure that the benefits reach the genuine beneficiaries.
• 1,113 Hospitals Removed: Along with suspending hospitals, 1,113 hospitals have been removed from the PMJAY panel. These hospitals were found to be involved in activities such as falsifying medical records or inflating patient counts, which violated the guidelines and trust of the program.
• ₹122 Crore Penalty: The National Health Authority (NHA) has also levied penalties amounting to ₹122 crore on 1,504 hospitals for fraudulent activities. The fines are being imposed as part of efforts to deter corrupt practices and ensure that healthcare services under PMJAY remain transparent and accessible.
• Anti-Fraud Unit Recommendations: The actions, including the suspension of hospitals and penalties, are based on the recommendations from the National Health Authority’s anti-fraud unit. This unit has been actively working to identify fraudulent claims and activities to maintain the integrity of the scheme.
Need for Regulation
• Stronger Regulatory Measures: The ongoing fraudulent activities in PMJAY highlight the urgent need for stronger regulatory mechanisms to monitor and control fraud. This includes establishing stricter auditing processes, better verification of claims, and enhanced accountability within the system.
• Parliamentary Standing Committee on Health and Family Welfare: The Parliamentary Standing Committee on Health and Family Welfare has raised concerns about the systemic fraud and unethical practices occurring within PMJAY. It has stressed the necessity of tackling these issues through comprehensive regulatory measures to protect the scheme’s integrity.
Government Response
• Zero-Tolerance Policy: The National Health Authority (NHA) has implemented a zero-tolerance policy towards fraud and abuse under PMJAY. This means that any hospital or service provider found indulging in fraudulent practices will face strict actions, including penalties, suspension, and removal from the panel.
• Fraud Detection and Categorization: The NHA has developed systems to detect different types of fraud early, including unnecessary medical procedures, falsification of patient data, and overbilling. These systems aim to catch fraudulent activities before they can cause significant damage to the scheme’s financial resources and public trust.
AB-PMJAY Benefits
• Annual Health Coverage of ₹5 Lakh: PMJAY offers health coverage of ₹5 lakh per family per year for secondary and tertiary care treatments. This ensures that beneficiaries can avail themselves of high-quality healthcare without worrying about crippling medical expenses.
• Coverage for 12.37 Crore Families: The scheme benefits approximately 12.37 crore families, covering nearly 40% of India’s population, particularly targeting the economically weaker sections. This wide coverage is designed to help reduce the financial burden of healthcare on lower-income families.
• Secondary and Tertiary Hospital Treatment: The PMJAY provides funding for secondary and tertiary care hospital treatments, covering various conditions like surgeries, diagnostics, and specialized care that might otherwise be unaffordable for many families.
• Comprehensive Healthcare: In addition to hospitalization costs, the scheme covers pre-hospitalization expenses (for up to 3 days) and post-hospitalization expenses (for up to 15 days), including diagnostics, medicines, and follow-up treatments, offering a holistic approach to healthcare.
Future Recommendations
• Proactive, Data-Driven Monitoring: Experts recommend implementing a proactive, data-driven monitoring system that uses real-time data and analytics to track hospital activities, claims, and patient treatment histories. This would allow for early detection of fraudulent claims, preventing larger fraudulent activities before they impact the system.
• AI-Based Technologies: The use of AI-based technologies is recommended to detect patterns of fraud more effectively. By integrating artificial intelligence, the NHA could predict fraudulent claims based on historical data, analyze suspicious activities, and reduce human errors in detecting fraud.
• Corrective Measures for Regulatory Shortcomings: The NHA is encouraged to take corrective actions to address any gaps in the existing regulatory framework that might allow fraudulent activities to persist. This includes revising the auditing process, updating rules for hospital claims, and ensuring that there is better coordination between the health ministry, NHA, and state-level health departments.
National Health Agency (NHA)
• Restructuring of NHA: The National Health Agency (NHA) was restructured and renamed for better implementation of PMJAY. The restructuring aimed at simplifying decision-making processes and ensuring a faster response to emerging challenges in implementing the scheme.
• Governing Board: The NHA operates with a Governing Board that includes representatives from the government, domain experts, and state representatives. The new structure enables quicker decision-making and ensures better accountability.
• Efficient and Transparent Decision-Making: The restructured NHA has been given full accountability and authority, allowing for more efficient, effective, and transparent decision-making. This will help speed up the implementation of PMJAY and improve its overall success.
Ayushman Bharat Scheme
• Vision of Universal Health Coverage (UHC): Ayushman Bharat aims to achieve Universal Health Coverage (UHC) by providing equitable healthcare access to all citizens. It is in line with India’s commitment to achieving the Sustainable Development Goals (SDGs), particularly SDG 3, which focuses on ensuring healthy lives and promoting well-being for all.
• Comprehensive Healthcare Approach: The Ayushman Bharat scheme is designed to address the entire healthcare system, focusing on prevention, promotion, and treatment at primary, secondary, and tertiary levels. This ensures that healthcare is available across all stages, from early prevention to advanced treatment.
Health and Wellness Centres (HWCs)
• Creation of HWCs: In February 2018, the government announced the creation of 1,50,000 Health and Wellness Centres (HWCs), transforming existing Sub Centres and Primary Health Centres. These centres provide Comprehensive Primary Health Care (CPHC), addressing the primary health needs of the population at the grassroots level.
• Services Provided: HWCs provide maternal and child health services, non-communicable disease care, free essential drugs, and diagnostic services, making healthcare more accessible to people in rural and underserved areas.
• Focus on Prevention and Health Promotion: HWCs emphasize prevention and health promotion by engaging individuals and communities to make healthy choices and reduce the risk of chronic diseases. This approach is designed to improve long-term health outcomes.
Pradhan Mantri Jan Arogya Yojana (PMJAY)
• Launch and Scale: Launched on September 23, 2018, PMJAY is the largest government-funded healthcare scheme globally, targeting over 50 crore beneficiaries. It aims to provide financial protection to economically vulnerable families who might otherwise struggle to afford secondary and tertiary healthcare services.
• Comprehensive Coverage: PMJAY offers health coverage of up to ₹5 lakh per family per year for hospitalization expenses, covering everything from medical examination and consultations to post-hospitalization follow-ups.
• Cashless and Paperless: PMJAY offers a cashless and paperless process for beneficiaries at the point of service, ensuring that families do not face financial hurdles when seeking treatment.
Eligibility for PMJAY
• Socio-Economic Caste Census 2011 (SECC 2011): Families eligible for PMJAY are identified based on the deprivation and occupational criteria of the SECC 2011 for both rural and urban areas.
• RSBY Coverage: Families that were covered under the Rashtriya Swasthya Bima Yojana (RSBY) but are not present in the SECC 2011 database are also included in PMJAY. This ensures that vulnerable families continue to benefit from the health coverage scheme.
Treatment Coverage Under PMJAY
• 1,949 Treatment Procedures: PMJAY covers 1,949 treatment procedures across 27 medical specialties, offering comprehensive medical coverage.
• All-Inclusive Care: The scheme includes all necessary expenses related to hospitalization, including diagnostic tests, medicines, medical consumables, accommodation, and follow-up care.
• Intensive and Non-Intensive Care: Both non-intensive and intensive care services are provided under PMJAY, including for complications arising during treatment.
Conclusion
• Regulatory Strengthening Needed: While PMJAY has been successful in expanding access to healthcare, stronger regulatory frameworks are needed to prevent fraud and ensure the scheme’s sustainability.
• Technological Integration: The adoption of AI and data-driven tools is vital for the effective monitoring and prevention of fraud.
• Healthcare Access for All: The expansion of HWCs and the implementation of PMJAY are key steps toward achieving Universal Health Coverage (UHC) and ensuring that all Indian citizens have access to high-quality healthcare.
Source: https://www.thehindu.com/sci-tech/health/over-3200-pmjay-hospitals-should-be-penalised-for-fraud-says-nha/article69326026.ece