Action taken against 1.6 lakh claims worth Rs 287 crores under AB-PMJAY till Aug 5: Mandaviya

New Delhi: Appropriate action against over 1.6 lakh claims worth Rs 287 crores has been taken under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) scheme till August 5 by state health agencies, the Lok Sabha was told on Friday.

Responding to a question, Union Health Minister Mansukh Mandaviya said 210 hospitals have been de-empanelled and 188 hospitals suspended due to their involvement in activities non-compliant with the guidelines issued by the National Health Authority (NHA) or the state health authority.

A penalty of Rs 20.71 crore has been levied, of which Rs 9.5 crore has been recovered, he said.

The NHA has set up a National Anti-Fraud Unit (NAFU) with the primary responsibility of prevention, detection and deterrence of fraud and abuse under AB-PMJAY, Mandaviya said.

The anti-fraud structure under the scheme has NAFU at the central level, followed by State Anti-Fraud Units. NHA uses Artificial Intelligence (AI) and Machine Learning (ML) technologies to detect suspicious transactions or potential frauds under the AB-PMJAY, the minister said.

These technologies are used for prevention, detection and deterrence of healthcare frauds in the scheme implementation and are helpful in ensuring appropriate treatment to the eligible beneficiaries, he added.

The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) scheme was launched on September 23, 2018, with the aim of providing a health cover of Rs 5 lakhs per family per year for secondary and tertiary care hospitalisation to over 12 crore poor and vulnerable families (approximately 55 crore beneficiaries).

The government of India launched the Ayushman Bharat Digital Mission (ABDM) to provide a platform that enables interoperability of health data within the health ecosystem to create a longitudinal Electronic Health Record (EHR) for every citizen, Mandaviya said.

ABDM comprises key registries such as the Ayushman Bharat Health Account (ABHA), Healthcare Professional Registry (HPR), Health Facility Registry (HFR), and Drug Registry. ABDM intends to make healthcare more transparent, secure, inclusive, accessible, and citizen-centric, he said.

As on August 8, 2023, a total of 44,19,86,761 Ayushman Bharat Health Accounts (ABHAs) have been created and 2,15,250 health facilities have registered on HFR. Besides, 2,13,784 healthcare professionals have registered on HPR and 29,28,29,789 health records have been linked with ABHA, Mandaviya added.

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