1-year-old national health insurance scheme tackles fraud

The Indian government's flagship health insurance scheme will soon require biometric verification for patient admissions and discharge processes to crack down on "ghost admissions".

Health Minister Dr Harsh Vardhan told ThePrint that as reports of fraud under the Ayushman Bharat scheme, which is also known as Pradhan Mantri Jan Arogya Yojana (PMJAY), emerge, the National Health Authority is issuing new guidelines and additional safeguards. “For example, we are going to introduce biometric authentication at the time of admission and discharge,” he said.

The government will also consider artificial intelligence tools for fraud detection. Fraud cases have also led the government to “de-empanel” around 100 hospitals and fine them INR25m ($351,000). In its “name and shame" initiative for averting fraud, the government has made public the names of 111 hospitals that were found involved in fraudulent practices.

Ayushman Bharat was launched by the government on 23 September 2018 to provide coverage for the poorest 100m families in the country. In the intervening one year, nearly 1,200 cases of fraud have been confirmed and action has been taken against 338 hospitals. Several people not eligible to benefit from the scheme managed to get fake PMJAY cards and enrolled in the scheme. In other cases, they assumed the identity of PMJAY cardholders.

In one case, the National Anti-Fraud Unit (NAFU) noticed that claims had been raised under the PMJAY for as many as eight deliveries by women in one house at the same time. However, there is no mechanism in place currently to detect all frauds. “Our staff manually monitor the outliers that reflect on the system. So, we are not able to capture all frauds that may be occurring. We are working on developing systems through artificial intelligence and algorithms, which will automatically red-flag the outliers,” said a NAFU official.

Source: The Times of India