New Delhi: About 250 hospitals have been de-empanelled for fraudulent practices and FIRs registered against common service centres for fudging beneficiary data within 10 months of implementation of Ayushman Bharat or Modicare.

Data provided to ET by the National Health Authority (NHA), the nodal agency for the health insurance scheme, reveals that in less than a year hospitals and common service centres have found innovative ways to beat the Ayushman system.

NHA De-empanels 250 hospitals after Ayushman health checkup

A single doctor conducting surgeries in four districts on the same day, patients charged for expensive procedures not conducted on them, multiple surgeries conducted on a single day late in the night, hysterectomies on men and fake beneficiaries issued cards by common service centres (CSCs) are some of the innovative ways used to beat the health insurance system, which promises an insurance cover of up to `5 lakh per annum per family for secondary and tertiary care.

The scheme is termed as the world’s largest government-funded healthcare programme targeting more than 50 crore beneficiaries. So far, 15,955 hospitals (7,992 private and 7,963 public) have been empanelled.

Several cases of fraud have been found by NHA’s National Anti-Fraud Unit which has, in turn, forwarded them to the state authorities for verification. These cases include even frauds in the beneficiary identification system.

Though the government has kept Census 2011 as the basis of identification of beneficiaries, cases have been found where ineligible persons have colluded with CSCs (authorised to identify beneficiaries under the Ayushman Bharat scheme) to deprive the real beneficiaries.

There were complaints from Agra and Pilibhit of such collusion.

An investigation was conducted and the complaints were found to be true. Later, 900 CSCs of Agra district and three CSCs of Pilibhit district were deactivated and FIR was lodged against the CSC incharge.

A senior official at NHA’s National Anti-Fraud Unit (NAFU), who did not wish to be identified, told ET, “The cases come to our notice either through direct complaints by the insured patients or mostly through our own system of checks.”

Fraud detection tech helped NAFU has a fraud detection module which triggers alerts when certain parameters do not match. For instance, if the same doctor’s name is thrown up multiple times, the system checks when the surgeries were conducted.

“With this, we got to know about the ghost charges –– how a single doctor was shown by the hospital of having conducted surgeries in four districts on the same day. This exposed one modus operandi,” the official said.

There have been numerous cases where unnecessary expensive procedures have been conducted on patients who did not require it so that the hospital could tap into higher packages’ reimbursement. In many cases, the billing was done even when that particular procedure was not conducted.

These were red-flagged by the system when it automatically detected sudden spurt in similar procedures in a single day in the same hospital. After complaints, the hospitals have been de-empanelled.

 

“NHA is also carrying out advanced analytics with the support of five companies and aberrant/outlier cases, suspect entities are flagged for scrutiny, investigation and due diligence. The medical audit team of NAFU analyses cases of over utilisation, abuse and flags off to state agencies for further verification. Action post detection of fraud, abuse or suspect behaviour includes issuance of show-cause notices to the hospital, suspension or de-empanelment, denial of fraudulent claims.”

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