Highlights and Status of Annual Report of PMJAY

PIB News Update: The annual report of National Health Authority (NHA) contained the salient features of the scheme, the institutional structure, important milestones, achievements, financial performance and audited accounts.

A zero tolerance approach has been adopted towards fraudulent activities   including claims. For this National   Anti-Fraud Unit (NAFU) has been created at NHA for overall monitoring and implementation of anti-fraud framework. NAFU is supported by State Anti-Fraud Units (SAFUs) at State level.

The proactive steps taken for prevention, detection, and deterrence of different kinds of fraud that could occur at   different stages of implementation are at the Annexure.

The Minister of State (Health and Family Welfare), Sh Ashwini Kumar Choubey stated this in a written reply in the Rajya Sabha here today.

Annexure

Steps taken for prevention, detection, and deterrence of different kinds of fraud under AB-PMJAY

1. Strong  Policy Framework: 

1. All packages prone to fraud are reserved for public hospitals or need mandatory pre-authorization and require detailed documentation before claims are paid.
2. National Anti-Fraud Unit (NAFU) has been created supported by State Anti-Fraud Units (SAFUs)

2. Beneficiary Empowerment:

1. Beneficiary empowerment is done by system generated messages to each beneficiary at the time of – e-card creation, hospitalization and discharge.
2. Feedback is collected through outbound calls and letters after treatment

3. Regular monitoring of empanelled hospitals:

1. Utilization data is analyzed on different triggers and results are shared with States for carrying out due diligence
2. Capacity building of the states is done on medical audits and Joint medical audits ofhospitals are done to identify any wrong doing.

4. Fraud Control IT enhancements:

1. Bio-authorization has been made mandatory at the time of admission and discharge. Pilot of the   same is done in 20 states and full implementation is done in 10 states.
2. Investigation app has been made functional in 16 states for prompt medical audits
3. Standard treatment Guidelines have been created for 30 abuse prone packages.

5. Use of Artificial Intelligence:

1. Partnership has been made with analytics companies to develop algorithms that can use big data to identify suspect transactions & entities. This would   go through Rule engines, Artificial Intelligence and Machine Learning   techniques.
2. SAS has been selected as a partner to develop a comprehensive Fraud Analytics   and Forensics solution to detect fraud proactively.