New Delhi: The same patient shown admitted in multiple hospitals during the same hospitalisation period, number of patients admitted in hospitals exceeding their declared bed strength, and fresh claims made for over 88,000 patients declared dead under earlier claims.
These are some of the alleged irregularities the Comptroller and Auditor General (CAG) of India has found in the implementation of the Union government’s flagship health insurance scheme Ayushman Bharat-Pradhan Mantri Jan Aarogya Yojana (PMJAY).
The CAG conducted a performance audit of PMJAY from September 2018 to March 2021. The report on its findings was tabled in the Rajya Sabha Tuesday.
Launched in September 2018, the PMJAY aims to provide a health cover of Rs 5 lakh per household per year for secondary and tertiary care hospitalisation to over 10.7 crore families from the poor and vulnerable section of the population.
The beneficiaries are decided based on the deprivation and occupational criteria of the Socioeconomic Caste Census (SECC) 2011.
“Audit noted that the PMJAY scheme, an ambitious and well-intentioned programme to provide healthcare access to the most vulnerable sections in the country, has had a strong positive impact on the economically weaker sections of the society who need healthcare facilities,” says the report.
However, it adds, the implementation of the scheme needs improvement in the light of the CAG’s findings.
The issues highlighted in the report include concerns about beneficiary identification and registration.
In the absence of adequate validation controls, errors were noticed in beneficiary databases such as invalid names, unrealistic date of birth, duplicate PMJDY IDs, and unrealistic size of family in a household, among others, it says.
For example, the report notes that, in 36 cases, two registrations each were made against 18 Aadhaar numbers. In Tamil Nadu, it adds, 4,761 registrations were made against seven Aadhaar numbers.
In several states, the CAG found a shortage of infrastructure, equipment, and doctors.
The report also says that some of the empanelled hospitals neither fulfilled minimum criteria of support system and infrastructure, nor conformed to the quality standards prescribed under PMJAY guidelines.
ThePrint tried reaching Union Health Secretary Sudhansh Pant, who is also the chief executive officer of the National Health Authority that operates PMJAY, by calls for a comment on the findings, but a response was still awaited at the time of publishing this report.
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‘Dead’ patients received treatment again
Data analysis of mortality cases by the CAG revealed that 88,760 patients were shown as having died during treatment specified under the scheme, but as many as 2,14,923 claims were shown as paid for fresh treatment in respect of these patients.
The maximum number of such cases were observed in Chhattisgarh, Haryana, Jharkhand, Kerala and Madhya Pradesh, the report says.
The analysis also reportedly showed that the IT system did not prevent registration under the same name in multiple hospitals during the same period of hospitalisation.
In 2,25,827 cases, even the simplest of validation rules were not documented properly, the report says. This, it adds, resulted in claims being paid even in cases where the date of surgery was found to be later than the patient’s discharge from hospital.
Since the scheme was launched, 3.57 crore claims amounting to Rs 42,433.57 crore had been settled (as of November 2022), but the CAG’s data analysis found that 39.57 lakh claims took more than the specified 12-hour period for approval of preauthorisation, says the 168-page report.
The audit report notes that, in January 2020 alone, there were 195 hospitals — 103 private and 92 public hospitals — that admitted more beneficiaries than their declared bed strength.
It calls out 12 hospitals in Jharkhand and one in Assam for allegedly indulging in various malpractices such as illegal collection of money from beneficiaries, repeated submission of the same photograph for multiple claims, and non-disclosure of facts.
“However, follow-up action like recovery of the amount of money collected and imposition of penalty, action against errant medical and paramedical professionals, de-empanelment of hospitals had not been initiated,” the report says.
In eleven states, inadequate validation checks — such as admission before preauthorisation, transaction dating before the scheme’s inception, surgery dating after a patient’s discharge, payment prior to submission of claims, non-availability/invalid dates and other entries — were noted, it adds.
The report also observes that delayed action in weeding out ineligible beneficiaries had resulted in ineligible people availing of benefits, and excess premium payment to insurance companies.
In four states — Andhra Pradesh, Madhya Pradesh, Punjab and Tamil Nadu — the CAG report notes “excess payment” of Rs 57.53 crore to hospitals for claims under PMJAY.
In many cases, the report says, private hospitals were paid for carrying out procedures that only public facilities can perform under PMJAY guidelines.
Among the health packages under PMJAY, 124 procedures were reserved for treatment in government hospitals under Health Benefit Package (HBP) 1.0, and 180 under HBP 2.0.
Andhra Pradesh and Punjab were among the states where private hospitals were found to have performed the public-hospital-reserved procedures for claims under PMJAY.
Another key finding from the audit is that a lack of speciality services in many states had forced beneficiaries to move to far-off places, which the CAG said causes hardship and inconvenience to them and may lead to out-of-pocket expenditure.
“There is a strong need to upgrade the speciality services of empanelled hospitals so as to fulfil the objective of the scheme,” says the report.
It also highlights instances where PMJAY beneficiaries had to pay out-of-pocket for treatment under the scheme. In Himachal Pradesh, for example, 50 beneficiaries of five hospitals had to manage their diagnostic tests from another hospital or diagnostic centre, and the cost was borne by the beneficiaries, the report notes.
(Edited by Sunanda Ranjan)
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