Lok Sabha Question No. 3245 (UNSTARRED), answered on 2021-12-17
Subject: Frauds by Private Hospitals under PMJAY
Ministry: HEALTH AND FAMILY WELFARE
Asked by: P.P. Chaudhary, Chandra Prakash Joshi, Sangamlal Kadedin Gupta, Pratap Chandra Sarangi, Rajendra Agrawal, Rajbahadur Singh, Krishna Pal Singh Yadav, Mahendra Singh Solanky

## GOVERNMENT OF INDIA MINISTRY OF HEALTH AND FAMILY WELFARE

## DEPARTMENT OF HEALTH AND FAMILY WELFARE

## LOK SABHA UNSTARRED QUESTION NO. 3245 TO BE ANSWERED ON 17 TH  DECEMBER, 2021

## FRAUDS BY PRIVATE HOSPITALS UNDER PMJAY

## 3245.  SHRI P.P. CHAUDHARY:

SHRI CHANDRA PRAKASH JOSHI:

SHRI SANGAM LAL GUPTA:

SHRI PRATAP CHANDRA SARANGI:

SHRI RAJENDRA AGRAWAL:

SHRI RAJBAHADUR SINGH:

DR. KRISHNA PAL SINGH YADAV:

SHRI MAHENDRA SINGH SOLANKY:

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

- (a)  whether  complaints  of  fraud  by  private  hospitals  under  the  Pradhan  Mantri  Jan Arogya Yojana have come to the notice of the Government;
- (b)  if  so,  the  details  of  fraud  committed  until  nowand  steps  taken  by  the  Ministry  to investigate and curb the same;
- (c)  whether  there  are  guidelines  in  place  for  private  hospitals  accepting  and  rejecting insurance claims under the scheme; and
- (d) 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  ABPMJAY  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  proactively, develop algorithms that can be used on large volume of data to identify suspect transactions and entities and risk scoring of hospitals and claims continuously.

As  of  14 th December,  2021,  the  anti-fraud  measures  taken  by  NHA  and  SHAs  have resulted in the de-empanelment  of 208 private healthcare providers. Penalties amounting to Rs. 16.80 crore are imposed against erring hospitals.

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.