CAG Report Uncovers Huge Discrepancies in Ayushman Bharat Policy, Patients shown as ‘dead’ getting treatment

New Delhi(India), 09/08/23: In its recent report, the Comptroller and Auditor General of India (CAG) made scathing judgements about the Ayushman Bharat-Pradhan Mantri Jan Aarogya Yojana (AB-PMJAY) scheme, stating that patients previously marked as ‘dead’ continued to receive treatment under the scheme.

The states of Chhattisgarh, Haryana, Jharkhand, Kerala, and Madhya Pradesh recorded the highest number of such incidents.

The report stated, “Data analysis of mortality cases in TMS 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. Audit further noted that in 3,903 of above claims amounting to ₹ 6.97 crore pertaining to 3,446 patients were paid to hospitals.”

Further data analysis revealed that the same patient could be admitted to various hospitals within the same hospitalisation period. The report also stated that there was no procedure in place to prevent patients from being admitted to several hospitals at the same time.

In July 2020, the National Health Authority (NHA) acknowledged the problem. According to the NHA, these occurrences occur when a baby is delivered in one hospital and transferred for neo-natal care to another hospital using the mother’s PMJAY ID.

In direct contrast to the NHA’s explanation, CAG’s data analysis revealed that 78,396 claims for 48,387 patients were initiated in the database, with the date of release for earlier treatment being later than the date of admission for another treatment of the same patient.

There were 23,670 male patients among these individuals. Cases of this nature were more common in Chhattisgarh, Gujarat, Kerala, Madhya Pradesh, and Punjab.

The report added, “Successful payment of such claims further indicates lapses on part of state health agencies (SHAs) in processing the claims without even verifying the requisite checks therein.”

The NHA, on the other hand, stated in August of last year that the problem was caused by non-synchronization of computer date and time, cases of neo-natal babies, and recording of pre-authorization after the date of admission.

When MoS Health and Family Welfare SP Singh Baghel told the Rajya Sabha in a written reply that the government employs artificial intelligence (AI) and machine learning (ML) to detect suspicious transactions and potential frauds under the AB-PMJAY scheme, the CAG report was tabled in Parliament.

According to Baghel, these technologies are used to prevent, detect, and deter healthcare fraud. He noted that the technologies are useful in ensuring that eligible recipients receive proper care. The minister informed the Upper House that as of August 1, 2023, a total of 24.33 crore Ayushman Bharat cards have been created under the initiative.

The CAG audit also revealed major flaws in the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) database regarding inconsistencies in beneficiary registration and validation. According to the research, numerous beneficiaries have been enrolled under the same mobile number. As beneficiaries of the PM-JAY scheme, about 9.85 lakh people are registered under the number 3 and 7.49 lakh persons are enrolled under the number 9999999999.

Other popular numbers for this purpose include 8888888888, 9000000000, 20, 1435, and 185397. “A data analysis of the BIS database revealed that there were many beneficiaries registered under the same or invalid mobile number. In total, 1119 to 7,49,820 beneficiaries were linked with a single mobile number in the BIS database,” according to the CAG study.

Furthermore, the research claimed that numerous empanelled health care providers (EHCPs) under the AB-PMJAY plan did not adhere to the mandated quality standards and criteria, which are critical to the safety and well-being of beneficiaries in care as well as the minimal prerequisites for empanelment.