Gujarat: Why 7 hospitals faced action under PMJAY within one year

However, this is not the only case related to alleged fraud under PMJAY scheme in the state. On November 13, Dhananjay Dwivedi, the Principal Secretary of Health, said that in the last one year, SAFU had visited 95 hospitals. Irregularities found in several of these hospitals had led to penalties amounting to Rs 20 crore being levied on them. Further, Rs44 lakh illegally charged from 1,024 beneficiaries had been returned to them.

However, of these 95 hospitals and doctors practising there, the state had found that seven hospitals and four doctors had committed the level of irregularities that deemed suspension from the scheme and the imposition of large monetary penalties, totalling Rs8.94 crore for loss caused to the government exchequer and patients.

The Indian Express takes a look at these cases:

1) ‘Unnecessary’ cardiology surgeries

Khyati Hospital, which was de-empanelled and permanently blacklisted from PMJAY-MA on November 13, picked up patients from a Mehsana village following a medical camp and performed angioplasty on seven of them. It was alleged that the procedure was unnecessary and carried out without consent. Bachhu Govaji Barot (77), who was among those who underwent the surgery, said the experience traumatised him. “We deserve justice and compensation,” he said. Six people, including the visiting cardiologist who performed the surgeries, have been arrested.

The visiting Cardiologist at Khyati Hospital, Dr Prashant Vazirani, was accused of having performed unnecessary angiography and angioplasty surgeries to make illicit gains from the scheme. He was also suspended from the scheme on November 13.

2) ‘Upcoding’ assisted institutional deliveries

Naritva Women’s Medical Studio in Ahmedabad was suspended from the PMJAY on October 25 and a penalty of Rs 1.22 crore was imposed on it.

Owned by Turning Point Health Care Pvt Ltd, the facility has three premises – in Bapunagar, New Naroda and Gota – in Ahmedabad. It is run by Group CEO Dr Vijay Pandya.

An investigation by the State Anti-Fraud Unit (SAFU) of PMJAY-MA scheme showed that the hospital had carried out “upcoding” in the claim for “Ruptured Uterus and Assisted Vaginal Delivery – Vacuum/ Episiotomy” procedure on several occasions. As part of upcoding, a healthcare provider bills for a service or procedure that is more expensive or severe than what was actually provided.

3) Healthy children presented as sick

Nihit Babycare Children Hospital in Rajkot is owned and run by Dr Hiren Mashru, a paediatrician. A tip-off from a whistleblower that led to a probe by the SAFU as well as auditors from the insurance company contracted for payouts under the PMJAY found that the hospital allegedly manipulated pathological laboratory reports of 18 children and uploaded false X-ray reports of 98 children, to ensure they were admitted to the hospital.

The fraud allegedly went on for 10 months. The hospital was suspended on June 27 and fined Rs 6.54 crore. Dr Mashru, was also suspended from the scheme on October 25, for manipulating and forging medical records of newborns.

4) False signatures and stamps

Sunshine Global Hospital, with branches in Vadodara and Surat, both run by M/s. Baroda Medicare Private Limited, was suspended from the PMJAY scheme on October 25. At the Vadodara facility, the SAFU found deficiencies in the Surgical Oncology department, leading to it being suspended from the specific Oncology cluster. The state also imposed a penalty of Rs 10.84 lakh on the hospital. Further, during an inspection, Surgical Oncologist Dr Mihir Shah was found to be engaged in alleged “upcoding” of surgical packages. He was also suspended from the scheme. Meanwhile, the sister hospital located in Surat was suspended from the Oncology Speciality of PMJAY after it was found that “false signatures and stamps” were made on the Tumour Board Certificate (TBC). The facility was fined to the tune of Rs 1.06 crore.

5) Infrastructural deficiency

While there were no medical or financial irregularities found at the Trust-run Everest Hospital in Una town of Gir Somnath district, the hospital was suspended from PMJAY because it did not have a Building Use (BU) permission from its local civic body. This hospital was suspended from all specialities on June 27. No fine was imposed.

6) Overcharging patients

At Shiv Hospital in Ahmedabad, a flying squad of the SAFU found that patients were being charged higher rates than permitted. It was suspended on June 27 and fined Rs 5,600.

7) Upcoding cancer radiation

Dr Ketan Kalariya, a Radiation Oncologist at Samanvay Hospitals in Junagadh, is accused of “upcoding” a radiation package claim of a patient uploaded on the PMJAY site. He was suspended from the scheme on October 25.

When hospitals threatened to suspend services under scheme

Under the hybrid Ayushman Bharat PMJAY-MA scheme run by the government of Gujarat, the insurer has a liability to pay claims up to Rs 1 lakh while the remaining is paid from a state government trust.

However, between August 2023 and February 2024, there was some tension between private hospitals empanelled under the scheme and the state government over dues to the tune of Rs 650 crore owed by the state to the hospitals for treating patients under the scheme.

After several months of negotiations with state health minister Rushikesh Patel assuring action, the matter was finally sorted out earlier this year with the intervention of the then Union Health Minister Mansukh Mandaviya.

Dr Bharat Gadhvi, Convener of the Gujarat Association of Hospitals and Nursing Homes and Allied Healthcare Services, told The Indian Express, “There were several issues with the payments pending to hospitals…However, they were sorted out to a large extent earlier this year with help from ministers Mandaviya and Patel…The procedure for payments to the hospitals was also amended at that time to everyone’s satisfaction.”