As cases of fraud in the government’s health insurance scheme Ayushman Bharat have begun to emerge, Union health minister Harsh Vardhan said on Tuesday, September 17, that nearly Rs 1.1 crore has been recovered from players found to be engaging in corrupt practices relating to the scheme.
He made this announcement at a press conference to celebrate a year since the government began implementing Ayushman Bharat as a health insurance scheme which aims to reach 10 crore families with an insurance cover of Rs 5 lakh per family. Government data says around 36 lakh people have availed themselves of treatment under the scheme.
In June, reports on frauds in the implementation of Ayushman Bharat emerged from Uttarakhand.
Over the last year, the government has discovered at least 1,200 cases of fraud. Ninety seven hospitals which had been empaneled under the scheme have been removed and made ineligible for the scheme.
As many as 376 hospitals are under investigation and the government has reportedly taken action against 338 of them. Action taken can range from issuing show cause notices, to de-empanelling them to filing FIRs against them. Six FIRs have been filed against hospitals and players suspected of engaging in fraud in the Ayushman Bharat health scheme.
Apart from the Rs 1.1 crore which has been recovered, Rs 1.3 crore has been imposed as penalty on other players.
“We have found these cases of fraud because we have robust detection and control measures built into the system. We want to send a message loud and clear that no fraud can be tolerated,” said Harsh Vardhan.
“We are trying to find and fix deficiencies in the system. Without any prejudice, we welcome all feedback,” he said.
The health insurance scheme, which has been allotted Rs 7,998 crore in the latest budget, has a ‘National Anti-Fraud Unit’ (NAFU) which is meant to detect and act against cases of fraud emerging in the scheme. The government says five “global firms” are said to be on board to identify suspicious transactions.
The anti-fraud unit comprises data analysts, medical experts as well as field investigators who can spot abnormal trends and start audits.
For example, a few things that can trigger the attention of the anti-fraud unit are cases where there appears to be more number of patients admitted in a medical facility than its capacity. The unit looks for cases where patients are discharged on the same day as a serious procedure or the same kind of procedures are done on members of the same family.
There is also a three-tiered grievance redressal system and a 24-hour call centre and helpline. Some popular grievances which are made to the unit are cases where hospitals charged patients for procedures that are supposed to be entirely free under this scheme or where hospitals entirely denied patients their treatment.
Hindu BusinessLine recently reported that in one case of fraud which NAFU detected, there were apparently eight deliveries by women with the same residence address and at the same time. NAFU found that these “patients” had fake eligibility cards and that they had also faked relationships with an actual beneficiary.
In Uttarakhand, “ghost patients” were apparently being referred from government hospitals to private doctors, who were claiming money under the scheme.