New Delhi: The Modi government has issued a circular to the states, directing them to implement fraud and abuse control measures across hospitals empanelled under the Pradhan Mantri Jan Arogya Yojana (PM-JAY).
The move comes amid concerns that the hospitals are not providing the stipulated free treatment to the beneficiaries.
The Pradhan Mantri Jan Arogya Yojana (PM-JAY), also known as Ayushman Bharat, is the Modi government’s flagship health insurance scheme and offers free treatment of Rs 5 lakh annually to beneficiaries.
“It has been brought to the notice of the National Health Authority (NHA) that certain hospitals have collected money from beneficiaries of PM-JAY, despite the fact that these costs are already incorporated in the packages and their rates,” reads the circular issued to state health authorities (SHAs) by Indu Bhushan, the chief executive officer of Ayushman Bharat and the NHA.
“This is against the underlying principle of the scheme to provide cashless treatment to the identified beneficiaries,” it adds.
The NHA has been set up by the government to implement the scheme through state-based health agencies. “Such activities of the errant hospitals need to be curbed and disciplinary action needs to be taken,” the circular, issued on 21 February, reads.
Also read: How Narendra Modi’s Ayushman Bharat is fighting India’s health emergency
‘Issue show-cause notices & temporary suspension of hospitals’
The circular, issued on the basis of recommendations from the national anti-fraud cell, has urged state health authorities (SHAs) to issue show-cause notices to the errant hospitals and ensure that money collected by them is returned to the beneficiaries.
It also directs the SHAs to withhold the payment to hospitals until detailed investigations and corrective measures have been taken. It further calls for “temporary suspension” of the hospitals.
The government has also identified that beneficiaries are unaware of the coverage of PM-JAY packages due to which it believes hospitals are able to charge money for free treatment.
“The beneficiaries need to be informed of the entitlement benefits under PM JAY and also about grievance redressal mechanisms available to them,” the circular reads. “Therefore, it is recommended that targeted IEC activities are conducted to generate awareness amongst beneficiaries and hospitals.”
Also read: Modi govt’s Ayushman Bharat could be behind sharp spike in rural health inflation
Scheme is a financial burden, says hospitals’ lobby
The hospitals, however, continue to point to rates offered for medical procedures under the scheme.
“It has been clearly mentioned in the rules that for how many days a patient can stay in the hospital after a particular treatment. However, in some cases, when patient stays for the longer duration — for instance, due to infection post-surgery — hospitals have charged for those extra days with no intention of doing an unethical practice,” said Girdhar J. Gyani, director general, Association of Healthcare Providers, India (AHPI), which represents 2,500 specialty and 8,000 smaller hospitals in the country.
He added that “hospitals are confused whether diagnostic tests or pre-hospitalisation procedures are part of the packages”.
“Instead of terming this as fraud, the government should revise the rates of hospitals, as fast as possible, so that the scheme does not become a financial burden on these hospitals,” he said.