Centre Rejects 3.56 Lakh Fraudulent Health Insurance Claims Worth Rs 643 Crore

The Indian government has rejected 3.56 lakh fraudulent health insurance claims worth Rs 643 crore and de-empanelled 1,114 hospitals under the Ayushman Bharat scheme, Union Minister of State for Health Prataprao Jadhav announced.

The government has also penalised 1,504 errant hospitals Rs 122 crore and suspended 549 hospitals.

The Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana is a flagship government scheme providing health coverage of Rs 5 lakh per family per year for secondary and tertiary care hospitalisation.

In October 2024, Prime Minister Narendra Modi expanded the AB-PMJAY to include all senior citizens aged 70 and above, providing them with Rs 5 lakh in free health coverage.

The scheme was expanded to cover six crore senior citizens belonging to 4.5 crore families.

The AB-PMJAY is governed by a zero-tolerance policy towards misuse and abuse and various steps are taken for the prevention, detection and deterrence of different kinds of irregularities that could occur in the scheme at different stages of its implementation, Jadhav said.

A robust anti-fraud mechanism has been put in place and National Anti-Fraud Unit has been set up with the primary responsibility for prevention, detection and deterrence of misuse and abuse under AB-PMJAY, Jadhav stated.

Under AB-PMJAY, triggers have been put in place in the Transaction Management System related to the upcoding of the health benefit packages, OPD to IPD conversion, ghost billing or treatment not rendered but claims raised, duplicate images or documents used for multiple claims, forgery or concealment and beneficiary impersonation or counterfeiting so that automatic flags are raised for proper investigation of such suspected claims.

Further, beneficiaries are verified through Aadhaar e-KYC only at the time of the creation of the card and have to undergo Aadhaar authentication at the time of availing services, which helps in mitigating the issues of duplicate registration and fraudulent claims, Jadhav said.

To enhance the detection of misuse or abuse, near real-time monitoring and AI-based systems are used to check hospital claims. Further, hospitals undergo random audits and surprise inspections to ensure the authenticity of claims.

Under AB-PMJAY, a three-tier grievance redressal system has been put in place at the district, state and national levels with dedicated nodal officers and committees at each level. Beneficiaries can also file their grievance using different mediums including web-based portal Centralised Grievance Redressal Management System ,central and state call centres, emails, letters to SHAs etc, Jadhav stated.

(With Inputs From PTI)