Flagging irregularities in the audit of the Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (PMJAY) health insurance scheme, the Comptroller and Auditor General of India (CAG) has said that Rs 6.97 crore was paid for the treatment of 3,446 patients who had previously been declared dead in the database. The scheme, launched in 2018, has been rolled out in both rural and urban areas with the aim of reducing out-of-pocket expenditure for the poor and vulnerable population seeking healthcare. In the performance audit, under the head “Treatment of a beneficiary shown as ‘died’ during earlier claim/treatment”, the CAG noted that “patients earlier shown as ‘died’ in TMS (the Transaction Management System of the scheme) continued to avail treatment under the scheme”. The audit noted that there were 3,903 such claims, pertaining to 3,446 patients, and that Rs 6.97 crore was paid to hospitals across the country. Kerala had the most number of such “dead” patients – 966 – whose claims were paid. A total of Rs 2,60,09,723 were paid for their “treatment”. Madhya Pradesh had 403 such patients, for whom Rs 1,12,69,664 was paid. Chhattisgarh came in third with 365 patients, for whose treatment Rs 33,70,985 was paid. According to existing guidelines, if a patient dies after admission to a hospital and before discharge, payment to the hospital is done following an audit. “During desk audit (in July 2020), audit had earlier reported to National Health Authority (NHA) that the IT system (TMS) was allowing pre-authorisation request of same patient who was earlier shown as ‘died’ during her/his earlier treatment availed under the scheme. NHA, while acknowledging the audit comment, stated in July 2020 that necessary check(s) have been put in place on 22 April 2020 to ensure that PMJAY ID of any patient who has been shown as died in TMS is disabled for availing further benefit under the scheme,” the CAG report said. According to the report, when the CAG flagged that the necessary checks were not followed, the NHA stated in August 2022 that “back-date of admission is allowed in the system for various operational reasons”. The CAG stated that the “reply is not tenable, as pre-authorisation initiation, claim submission and final claim approval" by the State Health Authority for “beneficiaries already shown as died during treatment earlier, indicate flaws in application and make it susceptible to misuse at user levels”. The CAG report has asked the NHA and the SHA to “ensure a comprehensive investigation of all cases to obviate the risk of irregular payment and malfeasance”. The health insurance scheme provides a cover of Rs 5 lakh per family every year for secondary and tertiary care hospitalisation across public and private empanelled hospitals in India. The audit report also flagged that in 2,231 hospital, there were instances of the same patient being admitted to multiple medical institutions simultaneously. The audit found a total of 78,396 such cases. Gujrat reported the most cases (21,514), followed by Chhattisgarh (9,640) and Kerala (9,632). The CAG report stated that in July 2020, "the desk audit has revealed that the IT systems (TMS) did not prevent any patient from getting admission in multiple hospitals during the same period of hospitalizations”. The NHA, while “acknowledging the lapse, stated (July 2020) that primarily these cases arise in scenarios where a baby is born in one hospital and shifted to neo-natal care in another hospital using PMJAY ID of mother.” The CAG, however, pointed out that contrary to the NHA claim, a total of 23,670 male patients were admitted to multiple hospitals during the same period of hospitalisation. As per the guidelines, dedicated Anti-Fraud Cells in the states are responsible for carrying out surprise inspections, imposing penalty, de-empanelment, prosecution, and other deterrence measures. According to the data on the recovery of penalties from defrauding hospitals in 13 states (NHA did not have data of the remaining states and Union Territories), Chhattisgarh and Meghalaya did not make a single recovery of penalties, with a 100 per cent of their recoveries pending. In Madhya Pradesh, 96.08 per cent of cases had no penalty recovery. The audit noted that in the NHA, "out of Rs 17.28 crore penalty imposed on 184 defaulting hospitals in these 13 States, recovery of only ₹ 4.96 crore had been effected."
