The Comptroller and Auditor General of India (CAG) has recently raised concerns about the efficacy of the Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (PMJAY) health insurance scheme. According to CAG's audit, a staggering Rs 6.97 crore was disbursed for the treatment of 3,446 patients who had previously been declared deceased in the scheme's database.
Under the CAG's performance audit, the irregularity was observed under the category "Treatment of a beneficiary shown as ‘died’ during earlier claim/treatment." The report noted that the guidelines for claims submitted by hospitals had distinct payment structures for cases involving mortality. Furthermore, it was stipulated that if a patient passes away after hospital admission but before discharge, payment to the hospital should occur following an audit of such cases.
However, the CAG's audit revealed that despite claims of corrective measures being put in place, the system allowed for patients previously marked as deceased to continue receiving treatment under the PMJAY scheme.
Data analysis revealed that 88,760 patients were documented to have died during treatment covered by the scheme. Shockingly, 3,903 claims totalling Rs 6.97 crore were paid out to hospitals in connection with 3,446 patients who had been marked as dead, CAG said.
The irregularities were noted to be widespread, with Chhattisgarh, Haryana, Jharkhand, Kerala, and Madhya Pradesh being identified as states with the highest number of such cases. Conversely, Andaman & Nicobar Islands, Assam, Chandigarh, Manipur, and Sikkim had the lowest number of cases.
An additional concern was raised about the functioning of the system itself. The CAG observed that the system not only allowed the initiation of pre-authorization requests for beneficiaries previously declared deceased but also permitted entries for admission dates, surgery dates, and discharge dates.
The National Health Authority (NHA) responded, justifying that the allowance of back-dating of admissions was due to operational reasons. However, the CAG found this explanation insufficient, arguing that the flawed application made the system susceptible to misuse and irregular payments.
The CAG report further requested comprehensive investigations by the NHA and State Health Agencies (SHA) to mitigate the risks associated with irregular payments and potential malfeasance. As the government strives to provide affordable and accessible healthcare to the vulnerable population, the revelations from the CAG audit underscore the need for greater scrutiny and oversight in the implementation of such critical schemes.
Launched in 2018 with the intention of alleviating the financial burden on economically disadvantaged individuals seeking healthcare, PMJAY has been rolled out across both rural and urban areas.
Ayushman Bharat PMJAY is the largest health assurance scheme in the world which aims at providing a health cover of Rs 5 lakh per family per year for secondary and tertiary care hospitalisation to over 12 crore poor and vulnerable families (approximately 55 crore beneficiaries) that form the bottom 40 percent of the Indian population. The households included are based on the deprivation and occupational criteria of the Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas, respectively, and state governments.
First Published: Aug 16, 2023 10:28 AM IST
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