Lok Sabha Question No. 325 (STARRED), answered on 2023-08-11
Subject: Fraudulent Transactions under AB-PMJAY
Ministry: HEALTH AND FAMILY WELFARE
Asked by: Sanjay Jaiswal

## GOVERNMENT OFINDIA

## MINISTRY OF HEALTH AND FAMILY WELFARE DEPARTMENTOFHEALTH AND FAMILYWELFARE

## LOKSABHA STARRED QUESTION NO. 325 TO BE ANSWERED ON THE 11 TH AUGUST, 2023

## FRAUDULENT TRANSACTIONS UNDER AB-PMJAY

## †*325. DR. SANJAY JAISWAL:

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

- (a) whether the Government proposes to implement Ayushman Bharat Digital Mission (ABDM) across the country;
- (b) if so, the details thereof;
- (c) whether any fraudulent transactions have been detected under AB-PMJAY and if so, the extent of fraud detected so far along with the amount recovered thereunder;
- (d) whether the Government has constituted any Anti-Fraud Unit to deal with the fraudulent transactions under the AB-PMJAY in various States;
- (e) if so, the details thereof, State/UT-wise and if not, the reasons therefor; and
- (f) whether the Government proposes to utilize Artificial Intelligence to detect fraud in AB-PMJAY and if so, the details thereof?

## ANSWER THE MINISTER OF HEALTH AND FAMILY WELFARE (DR MANSUKH MANDAVIYA)

- (a) to ( f) A Statement is laid on the Table of the House.

## STATEMENT REFERRED TO IN REPLY TO LOK SABHA STARRED QUESTION NO. 325 FOR 11 TH AUGUST, 2023

Government of India has launched Ayushman Bharat Digital Mission (ABDM) which aims to create a platform enabling interoperability of health data within the health ecosystem to create longitudinal Electronic Health Record (EHR) of every citizen. ABDM comprises of key registries such as Ayushman Bharat Health Account (ABHA), Healthcare Professional Registry (HPR), Health Facility Registry (HFR), and Drug Registry. ABDM intends to make healthcare more transparent, secure, inclusive, accessible, and citizen-centric.

As on 8 th August 2023, a total of 44,19,86,761 Ayushman Bharat Health Accounts (ABHAs) have been created; 2,15,250 health facilities have registered on HFR; 2,13,784 healthcare professionals have registered on HPR and 29,28,29,789 health records have been linked with ABHA.

Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) scheme was launched on 23 September, 2018 which aims at providing a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization to over 12 crores poor and vulnerable families (approximately 55 crore beneficiaries).

As on 05 th August 2023, appropriate actions against over 1.6 lakh claims worth Rs. 278 crores are taken by State Health Agencies as per guidelines issued by National Health Authority (NHA). 210 hospitals have been de-empanelled and 188 hospitals have been suspended due to their involvement in activities non-compliant with the guidelines issued by NHA or State Health Authority (SHA). A penalty of Rs. 20.71 crore has been levied against which an amount of Rs. 9.5 crore has been recovered.

National Health Authority (NHA) has set up a National Anti-Fraud Unit (NAFU) with the primary responsibility for prevention, detection and deterrence of fraud and abuse under AB-PMJAY. The anti-fraud structure under the scheme has NAFU at the central level, followed by State Anti-Fraud Units (SAFUs) at the State level.

NHA uses Artificial Intelligence (AI) and Machine Learning (ML) technologies to detect suspicious transactions / potential frauds under AB-PMJAY. These technologies are used for prevention, detection and deterrence of healthcare frauds in the scheme implementation and are helpful in ensuring appropriate treatment to the eligible beneficiaries.