Lok Sabha Question No. 3448 (UNSTARRED), answered on 2020-03-13
Subject: National Anti-Fraud Unit
Ministry: HEALTH AND FAMILY WELFARE
Asked by: Kuruva Gorantla Madhav, Chandra Sekhar Bellana, Adala Prabhakara Reddy

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

## LOK SABHA UNSTARRED QUESTION NO. 3448 TO BE ANSWERED ON 13 TH MARCH, 2020

## NATIONAL ANTI - FRAUD UNIT

## 3448. SHRI KURUVA GORANTLA MADHAV: SHRI CHANDRA SEKHAR BELLANA: SHRI ADALA PRABHAKARA REDDY:

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

- (a)  whether  the  National  Anti - Fraud  Units  (NAFU)created  for  overall  monitoring  and implementation  of anti - fraud  framework  have  conducted  reg ular  medical audits  to  check  any violations under the AB - PMJAY, if so, the details thereof and the extent to which these units remained effective in meeting their objective;
- (b) the number of cases registered under such units so far in the country, State/ UT - wise including Andhra Pradesh;
- (c)  the  number  of  cases  lying  pending/unresolved with  these  units,  State/UT - wise  including Andhra Pradesh; and
- (d) the necessary steps taken to resolve such pending cases expeditiously?

## ANSWER THE MINISTER OF STATE IN THE MINISTRY OF HEALTH AND FAMILY WELFARE (SHRI ASHWINI KUMAR CHOUBEY)

- (a): Under Ayushman Bharat -Pradhan Mantri Jana Arogya Yojana (AB - PMJAY), National Anti - Fraud  Unit  (NAFU)  has  been  created  at  National  Health  Authority  (NHA) for  overall monitoring  and  implementation  of  anti - fraud  framework.  NAFU  is  supported  by  State  Anti -Fraud Units (SAFUs) at the State level.

So  far,  joint  Medical  Audits  have  been  conducted  in  151  hospitals,  by  NAFU  an SAFUs. Negative findings were observ ed in 132 hospitals. The joint audits have been conducted across 14 States/UTs. (Assam, Bihar, Chhattisgarh, Chandigarh, Gujarat, Haryana, Jharkh Kerala, Madhya Pradesh, Punjab, Rajasthan, Uttar Pradesh, Uttarakhand and Andhra Pradesh)

After the medi cal audit, the reports are forwarded to the concerned SAFU for conducti detailed  investigation.  Based  on  the  investigation  outcomes,  either  the  case  is  cl disciplinary action (which may include showcause/ suspension/ levying penalty/ -empanelment or FIR) is taken against the hospital.

Also, AB - PMJAY IT system has in - built triggers, checks and balances for preventing and detecting  suspect  transactions  on  the  basis  of  algorithms  developed  internally.  The  s regularly shared with States for d ue diligence and medical audits.

(b) : As on 09.03.2020, based on the results of joint medical audits conducted by NAFU SAFUs,  five  (5)  hospitals  have  been  de - empaneled.  The  details  are  at  Annexure  I.    Other disciplinary actions like issuing show cause notice/ suspension/ penalty have been initiated in 70 hospitals. The State/UT - wise details are at Annexure II.

Parallel to above, as per information received from various States/UTs ,

- (i)  FIRs have been registered in 6 cases (5 in Uttarakhand and 1 in Jharkhand)

(ii) Action has been taken against 442 hospitals (including above).

(iii)  205 hospitals(including above)  have been de - empan lled so far in the country by various SHAs

State/UT wise details are available at https://www.pmjay.gov.in /de - empanelled

(c) : State/UT - wise details of the hospitals with pending actions based on joint medical a are at Annexure III.

As  regards  action  on  suspect  triggered  cases,  according  to  information  received States/UTs, for 662 hospitals inves tigation and suitable action is underway. The State/UT - wise details are at Annexure IV.

- (d): The following steps have been taken to resolve pending cases expeditiously -
- I. Advisories are regularly issued to States/UTs for conducting due diligence on pen ng cases and reporting the same to NAFU.
- II. For States where actions have been pending for a long time, the matter has been esc to the CEOs - SHA and Principal Secretaries (Health) for necessary action.
- III. System enhancement has been implemented to ensure that suspected cases are not paid till investigation is complete.

Annexure I

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| State/UT wise details of de- empanelled hospital as on 09.03.2020   | State/UT wise details of de- empanelled hospital as on 09.03.2020   |
|---------------------------------------------------------------------|---------------------------------------------------------------------|
| States                                                              | Number of Hospitals                                                 |
| Jharkhand                                                           | 2                                                                   |
| Uttarakhand                                                         | 3                                                                   |
| Grand Total                                                         | 5                                                                   |

Annexure  II

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| State/UT wise details of disciplinary cause/suspension/penalty (09.03.2020)   |                     | actions             | show-               |
|-------------------------------------------------------------------------------|---------------------|---------------------|---------------------|
| States                                                                        | Number of Hospitals | Number of Hospitals | Number of Hospitals |
| Chhattisgarh                                                                  | 11                  |                     |                     |
| Gujarat                                                                       | 4                   |                     |                     |
| Jharkhand                                                                     | 29                  |                     |                     |
| Kerala                                                                        | 4                   |                     |                     |
| Madhya Pradesh                                                                | 1                   |                     |                     |
| Punjab                                                                        | 6                   |                     |                     |
| Rajasthan                                                                     | 2                   |                     |                     |
| Uttar Pradesh                                                                 | 5                   |                     |                     |
| Uttarakhand                                                                   | 8                   |                     |                     |
| GRAND TOTAL                                                                   | 70                  |                     |                     |

Annexure III

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| State/UT-wise breakdown of the hospitals with pending actions based on joint medical audits (as on 09.03.2020)   | State/UT-wise breakdown of the hospitals with pending actions based on joint medical audits (as on 09.03.2020)   |
|------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------|
| States                                                                                                           | Actions Pending on Hospitals                                                                                     |
| Andhra Pradesh                                                                                                   | 0                                                                                                                |
| Assam                                                                                                            | 2                                                                                                                |
| Bihar                                                                                                            | 6                                                                                                                |
| Chhattisgarh                                                                                                     | 10                                                                                                               |
| Gujarat                                                                                                          | 4                                                                                                                |
| Haryana                                                                                                          | 8                                                                                                                |
| Jharkhand                                                                                                        | 7                                                                                                                |
| Kerala                                                                                                           | 0                                                                                                                |
| Madhya Pradesh                                                                                                   | 4                                                                                                                |
| Maharashtra                                                                                                      | 0                                                                                                                |
| Rajasthan                                                                                                        | 0                                                                                                                |
| Tamil Nadu                                                                                                       | 0                                                                                                                |
| Uttar Pradesh                                                                                                    | 20                                                                                                               |
| Uttarakhand                                                                                                      | 1                                                                                                                |
| GRAND TOTAL                                                                                                      | 62                                                                                                               |

Annexure IV

Details of hospitals where investigation and suitable action is underway

| Name Of State/Uts      |   No. of hospitals where investigation and suitable action is underway |
|------------------------|------------------------------------------------------------------------|
| Bihar                  |                                                                     29 |
| Chandigarh             |                                                                      1 |
| Chhattisgarh           |                                                                    182 |
| Dadra And Nagar Haveli |                                                                      2 |
| Gujarat                |                                                                     49 |
| Haryana                |                                                                     35 |
| Himachal Pradesh       |                                                                      9 |
| Jammu And Kashmir      |                                                                     15 |
| Jharkhand              |                                                                    110 |
| Karnataka              |                                                                      4 |
| Kerala                 |                                                                     31 |
| Madhya Pradesh         |                                                                     27 |
| Manipur                |                                                                      4 |
| Meghalaya              |                                                                      3 |
| Mizoram                |                                                                      2 |
| Nagaland               |                                                                      2 |
| Punjab                 |                                                                     12 |
| Tamil Nadu             |                                                                      9 |
| Tripura                |                                                                     16 |
| Uttar Pradesh          |                                                                     99 |
| Uttarakhand            |                                                                     21 |
| Grand Total            |                                                                    662 |