Lok Sabha Question No. 2057 (UNSTARRED), answered on 2019-11-29
Subject: Cost of Treatment under Ayushman Bharat
Ministry: HEALTH AND FAMILY WELFARE
Asked by: Imtiaz Jaleel Syed, Asaduddin Owaisi

## GOVERNMENT OF INDIA MINISTRY OF HEALTH AND FAMILY WELFARE DEPARTMENT OF HEALTH AND FAMILY WELFARE

## LOK SABHA UNSTARRED QUESTION NO. 2057 TO BE ANSWERED ON 29 TH NOVEMBER, 2019

## COST OF TREATMENT UN DER AYUSHMAN BHARAT

## 2057. SHRI SYED IMTIAZ JALEEL: SHRI ASADUDDIN OWAISI:

Will the Minister of HEALTH AND FAMILY WELFARE be pleased to state:

(a) whether there are disparities in cost of treatment between public and private hospitals under Ayushman Bharat Health Insurance Scheme even after the corrective step s taken in this regard;

- (b) if so, the reasons therefor;
- (c) whether National Health Authority (NHA) has investigated the matter and has formulated any guideline for private hospitals to prevent abuse thereof, if so, the details thereof; and
- (d) the other steps taken or being taken by the Government/NHA in this regard?

## ANSWER THE MINISTER OF STATE IN THE MINISTRY OF HEALTH AND FAMILY WELFARE

(SHRI ASHWINI KUMAR CHOUBEY)

- (a) &(b): No. Under Ayushman Bharat -Pradhan Mantri  Jan Arogya Yojana (AB PMJAY), there are 1393 health benefit packages and their rates have been defined. The packages are common for Public and Private hospitals empanelled under the scheme.  Th hospitals are paid on the basis of the rate fixed for a particular package.
- (c) : Following actions have been taken  to prevent abuse under AB - PMJAY -
- I. All admissions under AB - PMJAY require pre -authorizations from respective State Health Agencies (SHAs).
- II. A comprehensive set of Anti - Fraud  Guidelines  has  been  issued  from  the  time  o f launch of the Scheme
- III. Regular  Anti - Fraud  Advisory  Notes  are  issued  to  all  States  advising  them  on measures to be adopted to prevent, detect and deter fraud. 12 Advisory Notes h been issued so far to all implementing States.
- IV. All  packages  prone  to  fraud and  abuse  are  reserved  for  public  hospitals  or  need mandatory pre - authorization and require detailed documentation before claims ar paid.
- V. National  Anti - Fraud  Unit  (NAFU)  has  been  created  for  overall  monitoring  and implementation of anti - fraud framework. N AFU is supported by State Anti - Fraud Units (SAFU) at State level.
- VI. Guidelines for Recovery and Actions to be taken post confirmation of fraud hav been issued to all States
- (d) : Other Steps taken to prevent misuse under AB - PMJAY are as under:
- I. A close watch is being maintained on utilisation data through real time dashboards identify suspect cases for over utilization
- II. Suspect cases and entities are flagged based on different fraud control trigge results are shared with State agencies for further inv estigation
- III. Regular  joint  medical  audits  along  with  SAFU  of  hospitals,  both  random  an purposive, are conducted to identify any wrong doing.
- IV. Launch of Mobile Field Investigation App for prompt investigation of cases.
- V. Automation of anti - fraud triggers in I T system for real time detection of cases
- VI. Capacity building at the state levels so that they could also undertake similar a