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Treatment for the Dead, Discharge Before Surgery and the Many Problems of Ayushman Bharat

The first ever CAG report on the PMJAY highlights how the scheme has been riddled with corruption and visible fraudulence.

New Delhi: The Comptroller and Auditor General (CAG) report on the assessment of Pradhan Mantri Jan Arogya Yojana (PMJAY) – one of the two components of Ayushman Bharat scheme – has shown that despite being a highly important intervention of the Narendra Modi government to address health needs, it remains riddled with corruption of various kinds.  

The funding of the scheme is shared between the state governments and the Union in the ratio of 60:40. At the Union government-level, the National Health Authority (NHA) is responsible for scheme implementation. In states, the job has to be done through state health authorities (SHAs) and district implementations units. The scheme aims to provide Rs 5 lakh per family as per the strict criteria defined in the scheme. 

As per the NHA database, 24.42 crore beneficiaries have been registered for the scheme till date and Rs 67,456.21 crore has been spent on their hospital admissions. 

The CAG assessment included the time period of September 2018 to March 2021 – part of which coincides with the COVID-19 pandemic. The auditor test checked 964 hospitals in 161 districts of all 28 states and Union territories (UTs). Delhi, Odisha and West Bengal have opted out of this scheme. 

It is the first CAG report on the PMJAY. 

The auditors found large scale corruption in insurance claims settlement. It reported that not enough validation was done by the SHAs before releasing the claims to the hospitals which were empanelled under the scheme. It noted that in 2.25 lakh cases, the date of the ‘surgery’ done was shown to be later than the date of discharge. Of all such cases, more than 1.79 lakh were found in Maharashtra for which the claimed amount was over Rs 300 crore. 

In other instances, the hospitals had made claims and the SHAs had transferred money for dates even before the inception of the scheme. The payments were made to hospitals in some cases prior to submission of claims. In other cases, patients above 18 years of age were given treatment under ‘paediatric speciality packages’.

Also read: Ayushman Bharat Trivialises India’s Quest for Universal Health Care

The audit also found that in 45,846 claims, the date of discharge was earlier than date of admission. Furthermore, the audit found several cases where one patient had been shown to be hospitalised in multiple hospitals at one given point in time.

Lakhs of claims continued to be made against some who had been shown as ‘deceased’ in the database.

The data in the Transaction Management System (TMS) showed that 88,760 patients had died during treatment. And yet, 2,14,923 claims were shown as paid in respect of ‘fresh treatments’ given to these dead ‘patients’.  Almost Rs 7 crore was spent towards settling these claims in 24 states and UTs. The maximum number  of such cases were observed in Chhattisgarh, Haryana, Jharkhand, Kerala and Madhya Pradesh.

Lakhs of cards issued to beneficiaries were cancelled just as they were registered owing to malpractices. But the TMS – the system in place – failed to ensure that the pre-authorisation request for claims by hospitals made against these cards be restricted. As such, Rs 71.47 lakh were paid towards beneficiaries registered as per these ‘disabled’ cards.

As far as caution against bogus 11.04 lakh beneficiaries is concerned, the NHA generated many alerts to the SHAs. The SHAs could investigate only 7.07 lakh cards. The highest number of such fraud claims were made in Gujarat, Madhya Pradesh, Meghalaya and Uttar Pradesh.

One unique ID: Several beneficiaries

One of the biggest instances of graft in the implementation of this scheme was found in registration and identification of beneficiaries. 

The scheme stipulates that a unique PMJAY ID should be issued to beneficiaries once verification is complete. The audit discovered that 1.57 unique IDs appeared more than once in the database. In other words, all these IDs were duplicated. “In such circumstances, possibility of presence of ineligible beneficiaries in the Beneficiary Identification System [BIS] database cannot be ruled out,” the report said.

Besides Aadhaar numbers, the system also utilises the phone numbers of beneficiaries. The audit brought to light that there were large numbers of beneficiaries registered against the same or invalid mobile number. For example, 7.5 lakh beneficiaries were registered against the ‘9999999999’ mobile number and another 1.4 lakh under the ‘8888888888’ number. 

After the CAG report was released, an anonymous source of Union health and family welfare ministry has been quoted by PTI as saying that the scheme only used mobile numbers to reach out to the beneficiaries in case of any need and for collecting feedback regarding treatment, rather than for verification purposes.

Also read: Only Two-Thirds of Hospitals Under Ayushman Bharat Scheme Active Now: Report

The unnamed official went on to add: “AB-PMJAY identifies the beneficiary through Aadhaar identification wherein the beneficiary undergoes the process of mandatory Aadhaar based e-KYC. The details fetched from the Aadhaar database are matched with the source database and accordingly, the request for Ayushman card is approved or rejected based on the beneficiary details.”

What about Aadhaar?

But according to the audit report not all is well with Aadhaar identification either. Two registrations each were found to be made against 18 Aadhaar cards. On the other hand, in Tamil Nadu, 4,761 registrations were made against seven Aadhaar numbers, the audit found. 

What is further surprising is the fact that as per the scheme guidelines, the SHAs have to send SMS notifications to the contact number provided to check their eligibility. So in the backdrop of such large-scale duplication of numbers, it is unclear as to whether those SMS notifications were indeed sent, and if they were sent, who received them. 

“Mobile numbers are significant for searching records related to any beneficiary in the database, who may approach the registration desk without the ID,” the auditors say.

“In case of loss of e-card, identification of the beneficiary may also become difficult. This may result in denial of scheme benefits to eligible beneficiaries as well as denial of pre- and post-admission communication causing inconvenience to them,” they go on to add. 

While in its statement the ministry tried to downplay the duplication of mobile numbers, the audit report says the NHA had “agreed with audit observation” and assured that the deployment of BIS 2.0 would arrest this practice. And as such, the data entry operators would not be able to enter “random numbers” during the registration process. 

Hospital empanelment done without checks

According to the NHA database, 27,649 hospitals have been empanelled across India for providing services under this scheme. All public facilities with capability of providing inpatient services (community health centre-level and above) are deemed empanelled. As such, a little over 15,000 public and 12,000 private healthcare facilities are part of this scheme. 

An Empaneled Healthcare Provider (EHCP) has to fulfil criteria like the presence of round-the-clock support systems required for services like pharmacy, blood bank, laboratory, dialysis unit, post operative services, ICU care etc.

However, in Bihar, for instance, physical verification reports of 23 EHCPs disclosed that 16 of them did not fulfil the essential criteria. Other than Bihar; Andaman and Nicobar Islands, Assam, Chandigarh, Gujarat, Himachal Pradesh, Jammu and Kashmir, Manipur, Nagaland, Puducherry, Tripura and Uttar Pradesh figured in this list of states where hospitals got empanelled and failed to serve the purpose.  

“There were deficiencies such as medical equipment being out of order, lack of basic infrastructure such as IPD Beds, Operation Theatres, ICU care with ventilator support systems, Pharmacy, Dialysis Unit, Blood banks, Round-the clock Ambulance Services etc.,” the report said. 

Furthermore the auditors found that without doing enough checks and without the mandated physical inspection, respective district empanelment committees gave a go-ahead for the empanelment of 163 hospitals. Tripura ranked first with 103 such EHCPs followed by Uttarakhand (43) and Manipur (17). The NHA explained that the inspection couldn’t be done at these facilities owing to the “pandemic conditions.”

Many hospitals, on the other hand, after being empanelled for a certain set of fixed services, failed in providing them. For instance, In Maharashtra, the audit noted that 1,113 types of treatment facilities  were not provided in the hospitals located in Nandurbar, Washim, Osmanabad, Gadchiroli and Palghar Districts, and beneficiaries had to travel to other districts for treatment.

“In many states, lack of speciality services necessitated the beneficiaries to move far off places which causes hardship and great amount of inconvenience to the beneficiaries and may lead to out-of-pocket expenditure,” the report noted. Incidentally, one of the main purposes of the PMJAY is to reduce the out-of-pocket expenditure. 

Also read: All You Need to Know on Ayushman Bharat Digital Mission, Health IDs and Personal Records

Missing hospitals

But the existence of hospitals in the empanelled list did not necessarily translate into even their existence in the scheme – forget about the quality of services provided. In Andhra Pradesh, for example, out of 1,421 empanelled EHCPs, half of them submitted zero claims thus indicating they were not providing PMJAY services at all. While, another 81 of them submitted only 0-5 claims. Such examples were found in other states as well. 

“While accepting the observation, the NHA stated (August 2022) that due to the pandemic, EHCPs were reluctant to provide the services to PMJAY beneficiaries,” the audit report said, though it didn’t clarify the share of public and private facilities who were reluctant. 

However, the report did say what many experts and health activists have suggested so far: “There is a strong need to invest in public hospitals to improve and upgrade the quality of the existing health facilities in accordance with prescribed criteria [of the PMJAY scheme].”

What also limits the implementation of the scheme is the number of EHCPs empanelled vis-a-vis the number of beneficiaries. For example, in Bihar, 100% eligible people have been registered under the scheme. But there are only 1.8 EHCPs per lakh population – as against 26.6 in Goa. 

The EHCPs were also found to be indulging in various malpractices. In Assam, 18 EHCPs provided treatments for non-empanelled specialities to 1,149 beneficiaries for which total claims amounting to Rs 1.27 crore were paid to the hospitals. After the admission of the patient, from diagnosis to treatment, everything has to be cashless for patients. And yet, hospitals were found to be demanding money for different requirements. These, and other such acts of omission, have also led to SHAs taking the hospitals off the empanelled list. 

In 11 states, 241 hospitals were de-empanelled from the PMJAY either voluntarily or due to low performance and malpractices, as per the report. But in certain instances, such a step did not ensure stalling the payments. In Bihar, one Ananya Memorial Hospital was suspended in August 2019. And yet, the Bihar SHA paid it Rs 67,900 between 2018-20. 

The shoddy supervision by the SHAs have also led to circumstances where they have paid excess amounts to the hospitals. The audit found that in four states – Andhra Pradesh, Madhya Pradesh, Punjab and Tamil Nadu – excess payments amounting to Rs 57.53 crore were made.

Lastly, the auditors blamed the NHA for doing enough supervision over SHAs and releasing funds for them even when they had not spent their own share of the scheme, as per guidelines, or when the grants were lying unspent with them.

Also read: From National Health ‘Agency’ to ‘Authority’: Ayushman Bharat Body Restructured Yet Again

Not the first red flag

Though this report does raise many red flags about the scheme, this is not the first one. In fact, the first annual report of the scheme, which was published in 2019, had pointed to similar frauds. The subsequent annual reports remained silent on the quantum of frauds and made the relevant database inaccessible to the public. 

However, answering a question in Rajya Sabha last year, the minister of state of Union health ministry Bharti Pravi Pawar did say that 210 hospitals had been ‘de-empanelled’ and another 188 suspended from the PMJAY services. Even a penalty of Rs  21 crores had been levied on them but recovery worth Rs 9.5 crore could only be made. 

A paper titled ‘Critical Analysis of the World’s Largest Publicly Funded Health Insurance Program’ published in February 2023 said fraud in such schemes is one of the biggest contributors to the OOPE. “Health insurance fraud in the United states and Europe is estimated to be 10% of health-care spending. In India, that number could be as high as 35%,”  it said. 

Meanwhile, the health ministry, replying to a query in Rajya Sabha had said two days ago that artificial intelligence and machine learning  are being deployed to detect potential frauds in the scheme – something that Pawar had told parliament last year too.