The Ayushman Bharat Scheme, known for providing health insurance to millions of Indians, is facing serious challenges from fraudulent practices, prompting swift governmental action. Following the tragic deaths of two beneficiaries who underwent botched angioplasties at the Khyati Multi Specialty Hospital, the Gujarat government has initiated significant changes to curb misuse under the Pradhan Mantri Jan Arogya Yojana (PM-JAY).
Health Minister Rushikesh Patel announced the ban on free medical camps throughout the state, underscoring the government’s commitment to eliminate fraud linked to the PM-JAY scheme. This move is part of broader reforms aimed at enhancing transparency and addressing vulnerabilities in the healthcare system.
According to reports from The Federal, the State Health Agency (SHA) plans to digitalize operations and introduce artificial intelligence-enabled portals for quickly identifying fake or non-compliant documentation. This approach draws inspiration from success observed in the Delhi Health Department.
The SHA is set to introduce new Standard Operating Procedures (SOPs) for private hospitals participating in the PM-JAY scheme. These SOPs will ideally mitigate vulnerabilities identified within frequently exploited areas such as cardiology, oncology, pediatrics, and orthopedic surgery, where the possibility for fraudulent claims is highest due to large insurance payouts.
The statistics provided by the SHA indicate knee replacements and cardiac procedures as common and potentially vulnerable operations. The maximum insurance reimbursement under PM-JAY can be as high as Rs 5 lakh, with the Gujarat government promising additional financial assistance through the Maa Amrutam Yojna up to Rs 10 lakh.
To bolster oversight, the new SOP will implement a two-tier scrutiny mechanism. Once surgery is recommended by the attending physician, the SHA will require assessment by its medical team before approvals are granted. For operations within oncology, formal Tumor Board Certificates will now be mandatory, supported by online facilitation for faster processing.
Aside from regulatory enhancements, the SHA is forming State Anti-Fraud Units (SAFU) to carry out surprise inspections. This ensures active monitoring at both district and state levels throughout the year. Although the PM-JAY has provided coverage to millions since its inception five years ago, operational management has previously been conducted manually by the SHA, creating opportunities for manipulation.
Since the Khyati incident, investigations have intensified, leading to the cancellation of licenses for 12 doctors involved. Four hospitals at the forefront of these fraudulent activities have already been barred from the PM-JAY scheme, marking a total of 16 penalized institutions. Ongoing investigations, including those led by the Crime Branch, seek to dismantle these fraud rings altogether.
Meanwhile, reports from the Enforcement Directorate (ED) shed light on another dimension of fraudulent activities related to the Ayushman Bharat Scheme. Following raids conducted at 20 locations, approximately Rs 88 lakh was seized along with incriminatory documents and digital devices. The ED’s operations reveal deep-seated corruption and the illegal generation of fake Ayushman Bharat cards, which has compromised the integrity of the health coverage initiative.
Minister of State for Health Prataprao Jadhav noted the ED's findings during discussions held in Lok Sabha, emphasizing the commitment to address these alarming trends within the PM-JAY. The crackdown on the fabrication of Ayushman cards aims to restore public faith and operational integrity within the program.
The convergence of the ED's investigations and the Gujarat government's prompt reforms highlights the urgency of transforming the PM-JAY framework to safeguard the health services for the common populace. Each of these steps acknowledges loopholes previously exploited, solidifying the path toward accountable, transparent, and effective healthcare delivery.
With the future of the Ayushman Bharat PM-JAY hanging precariously on the outcomes of these initiatives, stakeholders remain vigilant. The combined efforts from different governmental agencies signal determination to restore the program's fundamental intent—providing accessible and reliable healthcare to all citizens.
