Lok Sabha Question No. 3740 (UNSTARRED), answered on 2022-03-25
Subject: Fraudulent transactions under the AB-PMJAY
Ministry: HEALTH AND FAMILY WELFARE
Asked by: Chandra Prakash Joshi, Sangamlal Kadedin Gupta, P.P. Chaudhary, Behanan Benny, Mahendra Singh Solanky, Rajbahadur Singh, Brijbhushan Sharan Singh, Jagdambika Pal, Pratap Chandra Sarangi

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

## LOK SABHA UNSTARRED QUESTION NO. 3740

## TO BE ANSWERED ON 25 TH  MARCH, 2022

## FRAUDULENT TRANSACTIONS UNDER THE AB-PMJAY

## 3740.  SHRI CHANDRA PRAKASH JOSHI:

SHRI RAJBAHADUR SINGH:

SHRI PRATAP CHANDRA SARANGI:

SHRI BRIJBHUSHAN SHARAN SINGH:

SHRI MAHENDRA SINGH SOLANKY:

SHRI BENNY BEHANAN:

SHRI JAGDAMBIKA PAL:

SHRI SANGAM LAL GUPTA:

SHRI P.P. CHAUDHARY:

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

- (a)  whether  the  Government  has  taken  note  of  the  fraudulent  transactions  recorded  at  Empanelled Healthcare Providers under AB-PMJAY;
- (b) if so, the details thereof along with the reasons therefor, State/UT-wise;
- (c) the corrective steps taken/being taken by the Government in this regard; and
- (d)  whether  the  Government  has  laid  down  any  guidelines  for  private  hospitals  with  regard  to accepting and rejecting insurance claims under the Scheme and if so, the details thereof?

## ANSWER THE MINISTER OF STATE IN THE MINISTRY OF HEALTH AND FAMILY WELFARE (DR. BHARATI PRAVIN PAWAR)

(a) to (d): Ayushman Bharat -Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is governed on a  zero-tolerance  approach  to  any  kind  of  fraud  viz.  suspect/non-genuine  medical  treatment claims,  impersonation  and  up-coding  of  treatment  packages/procedures  etc.  National  Health Authority -the implementing agency of AB-PMJAY has issued a comprehensive set of anti-fraud guidelines.  Regular  anti-fraud  advisories  are  issued  to  States/UTs.  National  Anti-Fraud  Unit (NAFU) is created at NHA for overall monitoring and implementation of anti-fraud framework supported  by  State  Anti-Fraud  Units  (SAFUs)  at  State  level.  All  claims  require  mandatory supporting documents along-with on-bed patient photo before approval and payment. The feature of Aadhar-based biometric verification of beneficiary at the time of admission and discharge is launched at all private hospitals. Use of artificial intelligence and machine learning is made for a comprehensive fraud analytics solution to detect fraud pro-actively, develop algorithms that can be used on large volume of data to identify suspect transactions and entities and risk scoring of hospitals and claims.

State/UT-wise details of penal action taken in respect of hospital transactions are at Annexure.

As per  the  terms  and  conditions  of  empanelment,  hospitals  cannot  deny  treatment  to  genuine beneficiaries  of  the  scheme.  Medical  treatment  claims  are  filed  by  private  hospitals  with insurance companies/trust, as per the case. The insurance company/trust settles these claims after verifying the genuineness thereof.

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## State/UT-wise details of penal action taken in respect of hospital transactions

|   S.No | State / Union Territory   | Hospital Transactions   |
|--------|---------------------------|-------------------------|
|      1 | Assam                     | 52                      |
|      2 | Bihar                     | 140                     |
|      3 | Chhattisgarh              | 8,586                   |
|      4 | Haryana                   | 101                     |
|      5 | Himachal Pradesh          | 2                       |
|      6 | Jammu And Kashmir         | 7                       |
|      7 | Jharkhand                 | 3,767                   |
|      8 | Karnataka                 | 7                       |
|      9 | Kerala                    | 159                     |
|     10 | Madhya Pradesh            | 503                     |
|     11 | Nagaland                  | 1                       |
|     12 | Puducherry                | 4                       |
|     13 | Punjab                    | 2,065                   |
|     14 | Tripura                   | 60                      |
|     15 | Uttar Pradesh             | 136                     |
|     16 | Uttarakhand               | 3,016                   |