New Delhi: In a rare instance of its kind, the Union health ministry issued a press release on August 17 attempting to fact-check media reports on the recent Comptroller and Auditor General (CAG) report on Ayushman Bharat that pointed to large-scale corruption in the scheme.The press release is titled ‘Myths Vs Facts: Media Reports claiming AB PM-JAY beneficiaries who have been declared dead on the system availing treatment at hospitals are misleading’.However, in the four-page press release, the ministry did not cite a single specific example wherein the media reports had erred in quoting the CAG report per se, for instance to say the CAG report was misquoted or quoted out of context. All that the release did was to counter the shortcomings found in the CAG report without blaming the auditor. Instead, it put the onus on journalists for having quoted various parts of the report.Sample this: “There have been media reports claiming that the Comptroller and Auditor General of India (CAG) has flagged that treatments have been booked for AB PM-JAY beneficiaries who have been declared dead on the system. The reports further claim that the same beneficiary had been found to avail treatment across two hospitals at the same time. These media reports are completely misleading and ill-informed,” the ministry’s release said.The release goes on to qualify: “The hospitals are allowed to initiate request for pre-authorisation [for the purpose of availing claims] upto three days post the date of admission in the hospital….In some cases, the patients got admitted and before their pre-authorisation was raised, they died during the treatment.”In other words, the ministry said that patients might have died in the time period ranging from date of admission in the hospital to the date on which the pre-authorisation request was raised by the hospital concerned. And therefore, it was perfectly legitimate to pay a claim to the hospital even if the patient died during this period as the request might have been raised after the admission, in a back-dated manner.But did the CAG report really find a flaw with this process? It doesn’t seem so. The CAG report said: ” [The] IT system, TMS, was allowing pre-authorisation requests of [the] same patient who was earlier shown as ‘died’ during her/his earlier treatment availed under the scheme.”There is a key difference between the ministry’s claim and the CAG’s report. The former said the pre-authorisation requests were raised by the hospitals during an ongoing treatment. On the other hand, the CAG report said, such requests were put up for the same people who were shown dead in the earlier treatments.In fact, the CAG report went on to add: “Data analysis of mortality cases in TMS [Transaction Management System] revealed that 88,760 patients died during treatment specified under the Scheme. A total of 2,14,923 claims shown as paid in the system, related to fresh treatment in respect of these patients.”This is what The Wire, and some other media publications too, had said in their articles.Though now the ministry is finding fault in this reporting, the CAG report says that the National Health Authority (NHA) – the body that implements Ayushman Bharat Scheme at the Centre – had acknowledged this finding of the auditor.“NHA, while acknowledging the audit comment, stated in July 2020 that necessary check(s) have been put in place on 22 April 2020 to ensure that PMJAY ID of any patient who has been shown as died in TMS is disabled for availing further benefit under the scheme.” (PMJAY or Pradhan Mantri Jan Arogya Yojana is part of Ayushman Bharat Scheme under which the eligible families get Rs 5 lakh insurance cover.)However, despite the assurance, the CAG found that the gap continued to exist. “Audit noted that patients earlier shown as ‘died’ in TMS continued to avail treatment under the Scheme,” the report said.The CAG had said that not only were patients who had been shown dead earlier later registered for fresh pre-authorisation requests, but the system was so faulty that it allowed entering dates for “all other entries such as admission date, surgery date and discharge dates” for them.The ministry gave another argument about the back-dated pre-authorisation. “There are also many instances where the patient is admitted in the hospital as a private patient (self-paid) but subsequently on discovering about the scheme and their eligibility under the scheme, the patient requests the hospital to register them under the scheme for free treatment. This feature to request for back-dated pre-authorisation helps in saving out-of-pocket expenditure of the beneficiaries.”The ministry had given the same clarification to the CAG, as per the report. And the auditor termed it untenable.“The reply is not tenable, as pre-authorisation initiation, claim submission and final claim approval by Implementation Agency/State Health Authority for beneficiaries already shown as dead during treatment earlier, indicate flaws in application and make it susceptible to misuse at user levels,” the CAG said.The release goes on to add that more than 50% of such cases were detected in public hospitals, which have no reason or incentive to commit fraud because the insurance claim would be deposited in these hospitals only. The CAG report made no such distinction.According to the CAG, about Rs 7 crore were paid to settle some such claims.Source: CAG reportOne patient, many claimsThe second charge that the ministry has tried to dispel is the CAG finding that one patient was shown to be availing treatment at different hospitals at one given point in time – thus indicating bogus patients were being treated. The CAG had said, “Data analysis during desk audit (July 2020) revealed that the IT system (TMS) did not prevent any patient from getting admission in multiple hospitals during the same period of hospitalisations.”The ministry’s release denied the charge. It said that a child under five years of age and a mother are registered under the same card. “Accordingly, Ayushman Card can simultaneously be used for children and either of parents in two different hospitals,” it said. The ministry went on to explain that if during delivery, a mother is treated at a hospital and the child requires neonatal care which is not present at that hospital, then the child would be shifted to another facility and would be registered under the same card.The ministry gave the same reply to the CAG, which the latter rejected. The CAG said, “Contrary to the claim of NHA, these patients included 23,670 male patients.”It had another important finding on bogus claims. It found that the date of discharge for many patients for an earlier treatment was later than the date of admission for another treatment of the same patient. The CAG detected more than 40,000 such patients.The ministry nonetheless claimed that it has a “four-step robust claim processing system” and hospitals are penalised for such frauds too.Multiple IDs registered on one phone numberThe CAG finding which grabbed the maximum attention in media reports was the one in which it said that multiple beneficiaries were registered with the same mobile number. It said 7.5 lakh beneficiaries were registered against the ‘9999999999’ mobile number and another 1.4 lakh under the ‘8888888888’ number.The ministry said it was a useless finding as far as “operational and financial implications as beneficiary identification process” are concerned. The first defence that the ministry gave was that the mobile numbers were registered only for the purposes of “reaching out to beneficiaries in case of any need” and for the “feedback” on treatment given, and not necessarily for the verification of beneficiaries.However, the ministry did not explain if the phone numbers were the same for so many people, how could the concerned officials reach out to so many different beneficiaries.The ministry also said the government uses “Aadhaar based e-KYC” for the verification purpose. “The details fetched from the Aadhar database are matched with the source database and accordingly, the request for Ayushman card is approved or rejected based on the beneficiary details,” it explained.But is the Aadhaar-based verification fool-proof? The CAG could find violations against this too, at least in Tamil Nadu, wherein it discovered 4761 registrations were made against seven Aadhaar numbers.The ministry further added that many beneficiaries keep changing their mobile numbers, but how this fact has a bearing on the duplication of random phone numbers like 8888888888 or 9999999999 for so many beneficiaries is not clear.The ministry said that there is no room to deny treatment if the beneficiary doesn’t carry a valid mobile number and the mobile number inconsistency has no bearing on the scheme workflow. However, to the CAG, it had acknowledged this lacuna, and been quoted thus in its report” “NHA, while agreeing with audit observation, stated (August 2022) that with the deployment of BIS 2.0, this issue shall be resolved.”Other findingsThe ministry’s release dealt with three of the CAG’s findings. But on many others, the ministry has remained silent. Some of them are are as follows:In as many as 2.25 lakh cases, the date of the ‘surgery’ done was shown to be later than the date of dischargePayments transferred against such claims by hospitals which were dated even before the scheme was rolled outPayments made to hospitals on dates that preceded submission of claimsBogus claims made for adults being treated under paediatric packagesHospitals empanelled under the scheme not fulfilling the mandatory criteriaEmpanelment of hospitals without physical verificationFailure of hospitals to provide services after empanelmentAfter empanelment, hospitals submitting only 0-5 claims, indicating they were not providing services under the schemeExcess payment amounting to Rs 57.53 crore were made to the empanelled hospitalsOne unique PMJAY ID, which is to be issued to each beneficiary, was found to registered against names of multiple beneficiariesIneligible households registered as beneficiariesBeneficiaries being charged for treatment when it is supposed to be totally free.As a matter of process, before the CAG report is finalised and tabled in the parliament, the auditor shares the findings with the department/ministry concerned to give it a chance to respond. The arguments given by the ministry in the August 17 press release were almost the same as to what it said to the CAG, as documented in the report. Despite the CAG rejecting them, they have been duplicated in the press release.
