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171 hospitals de-empanelled & ₹4.5 cr fine imposed for fraud under Ayushman Bharat scheme

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On January 03, 2020 the National Health Authority(NHA) which is the apex body regulating and implementing Ayushman Bharat health insurance scheme, Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB- PMJAY) has de-empanelled a total of 171 hospitals and also imposed penalty of Rs 4.5 crore on hospitals for committing fraud and indulging in malpractices under the Ayushman Bharat health insurance scheme.National Health Authority’s findings on misuse of e-cards:

i.6 hospitals in Uttarakhand and Jharkhand have been lodged and FIR (First Information Report).

ii.Violations detected by NAFU: The National Anti-Fraud Unit (NAFU) that is responsible for conducting regular medical audits to check any medical violations under the Ab-PMJAY scheme, detected suspect e-cards on the basis of algorithms developed internally by it and shared with states for due diligence and action.

iii.Fake card generation: A fake e-card cannot be generated as the process requires a go-ahead by authorised persons based on supporting documents and also needs final approval of the state health agency officials. These procedures are required not only to create an e-card but also to add any additional family members.

iv.Card misuse by hospitals: The PMJAY health insurance cover provides health cover of Rs 5 lakh per family and not just Rs 5 lakh per e-card. There is no package under the scheme which is free for government. But there are reserved packages reserved by the govt. hospitals such as abuse-prone packages.

  • It was detected by NAFU that several private hospitals performed these govt. reserved procedures and blocking/submitting the same under a different package name or as unspecified package.

Ayushman Bharat scheme- PMJAY:

  • PM-JAY is the world’s largest health insurance scheme fully financed by the government. The scheme was launched in 2018 under the aegis of Ministry of Health and Family Welfare (MoHFW) in India aimed at making necessary interventions in primary, secondary and tertiary health-care systems.
  • It is also known as National Health Protection Scheme.
  • Health insurance cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization to over 10.74 crores poor and vulnerable families will be provided under the scheme.

About National Health Authority:
Fact- National Health Authority is the successor of National Health Agency, which was functioning as a registered society since 23rd May, 2018. It was reconstituted as National Health Authority on 2nd January 2019.
Chief Executive Officer(CEO)- Dr. Indu Bhushan (ceo of AB-PMJAY)
Deputy CEO- Dr Praveen Gedam (Deputy CEO of AB-PMJAY)