AI Helps Ayushman Bharat Scheme Battle Fraudulent Claims: 210 Hospitals De-Empanelled, Over 5 Lakh Cards Disabled

Swarajya Staff

Jul 15, 2023, 03:59 PM | Updated 03:56 PM IST

Representative Image
Representative Image

A penalty amount of Rs 9.5 crore has been recovered as a result of an anti-fraud initiative using artificial intelligence and machine learning.

This initiative is aimed at protecting Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), the world's largest government-run insurance scheme.

Based on the information of fraud obtained through this initiative, 5.3 lakh Ayushman cards have been disabled and 210 hospitals have been de-empanelled.

Since the inception of the AI initiative, around 0.18 per cent of the total authorised hospital admissions under the Ayushman Bharat Scheme have been confirmed as fraudulent.

As part of the anti-fraud drive, 188 hospitals have been suspended and a penalty of Rs 20.17 crore has been levied.

To enhance fraud detection and prevention, the Ministry of Health has implemented a comprehensive fraud analytics solution that utilises artificial intelligence.

"Besides routine checks, the use of AI is now made for a comprehensive fraud analytics solution to detect fraud pro-actively, develop algorithms that can be used on large volume of data to identify suspect transactions and entities and risk scoring of hospitals and claims,” the Ministry noted, reports The Hindu.

The National Health Authority (NHA), which is responsible for implementing AB-PMJAY, had previously issued a comprehensive set of anti-fraud guidelines.

These guidelines serve as a framework for combating fraud and ensuring the integrity of the insurance scheme.

“Anti-fraud advisories were also issued to States/UTs. National Anti-Fraud Unit (NAFU) was created at NHA for overall monitoring and implementation of anti-fraud framework supported by State Anti-Fraud Units (SAFUs) at State level,” a senior Health Ministry official was quoted as saying by The Hindu.

The scheme strictly adheres to a zero-tolerance approach towards any form of fraud, including suspicious or non-genuine medical treatment claims, impersonation, and up-coding of treatment packages or procedures.

According to the ministry, all claims must be accompanied by mandatory supporting documents and a photograph of the patient on the bed. Only after these requirements are fulfilled, the claims will be approved and payment will be made.

Furthermore, private hospitals have implemented the Aadhar-based biometric verification feature for beneficiaries during admission and discharge procedures.

The programme claims to have resolved 99 per cent of all registered grievances (3.93 lakh) as of 4 July this year.

According to the government data, AB- PMJAY has been implemented in 33 States and UT, with a total of 24 crore health cards issued so far.

The government is now focused on achieving Ayushman card saturation, deploying health kiosks, ensuring timely settlement of claims, expanding the network of empanelled hospitals, and increasing the uptake of the scheme.

The Health Ministry is actively working on the implementation of the Ayushman Bharat Digital Mission, which aims to establish a national digital system to safeguard the security, confidentiality, and privacy of health-related personal information.

The Pradhan Mantri-Ayushman Bharat Health infrastructure mission has a financial outlay of Rs 64,180 crore from 2021-22 to 2025-26, and the government is now working at developing and strengthening health and wellness centres, block public health units, expanding disease surveillance systems, and enhancing pandemic research through a multi-sector national institutions platform.

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