CHANDIGARH: Rampant fraud has plagued Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, with empanelled hospitals in the region inflating insurance claims. The three states alone account for over 13% fake claims detected nationwide, raising serious concerns about misuse and accountability.
Of the 6.66 crore claims processed by the National Anti-Fraud Unit, 2.7 lakh claims from private hospitals—amounting to Rs 562.4 crore—were found to be inadmissible due to abuse, misuse, or incorrect entries. Punjab, Haryana, and Himachal Pradesh together account for Rs 74.5 crore of these fraudulent claims.
Haryana reported the highest number of such claims in the region, followed by Punjab and Himachal Pradesh, according to data shared by the Union health ministry in Rajya Sabha in response to a query by MP A D Singh regarding fake billing under AB-PMJAY.
In Haryana, private hospitals submitted inadmissible claims worth Rs 45.03 crore due to abuse, misuse, or incorrect entries. Punjab followed with Rs 28.7 crore in fraudulent claims, and Himachal Pradesh with Rs 75.65 lakh in such cases.
In response to another query by MPs Javed Ali Khan and Ramji Lal Suman, the Union health ministry revealed cases where multiple beneficiaries were registered under a single mobile number. Punjab reported 30,001 such cases, Haryana 13,555, and Himachal Pradesh 2,892.
The ministry reiterated AB-PMJAY operated on a zero-tolerance policy toward fraud and abuse. Various measures have been implemented to prevent, detect, and deter fraudulent activities at different stages of the scheme's implementation. The National Health Authority set up the National Anti-Fraud Unit, which works closely with state anti-fraud units (SAFUs) to investigate and take joint action against fraud.
To strengthen enforcement against misuse and abuse under AB-PMJAY, the ministry informed that the National Health Authority issued guidelines outlining several punitive measures. These include suspending, blacklisting, or de-empanelling hospitals found guilty of malpractice. Additionally, fraudulent claims are rejected, and penalties or legal actions are imposed on the hospitals concerned.
To enhance fraud detection, near real-time monitoring and AI-based systems are used to scrutinise hospital claims. Random audits and surprise inspections are conducted to verify the authenticity of claims, while state health agencies carry out regular desk and field medical audits. As a result of these stringent measures, 1,114 hospitals have been de-empanelled, and 549 have been suspended under AB-PMJAY.
Additionally, the National Anti-Fraud Unit has deployed 57 advanced technologies, including rule-based triggers, machine-learning algorithms, fuzzy logic, image classification, and de-duplication, to detect cases of misuse and abuse. Other measures, such as enhanced access controls for NHA IT system, near real-time dashboards to flag suspicious cases, continuous database monitoring and cleansing, and advanced data analytics techniques, have also been implemented to strengthen the integrity of AB-PMJAY.
Under the flagship scheme, govt provides health cover of Rs 5 lakh per family per year for secondary and tertiary care hospitalisation.
Recently, the scheme was expanded to cover senior citizens aged 70 years and above irrespective of their socio-economic status under ABPMJAY with Vay Vandana Card.
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