Health Scheme: CAG points to fault lines in AB-PMJAY

NEW DELHI: Treatment of a beneficiary already shown as ‘died’ during earlier claim/treatment, admission of the same patient in multiple hospitals during the same hospitalisation period and number of patients admitted to a hospital exceeding its declared bed strength.

These are some of the irregularities cited by the CAG in its audit of the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) that was tabled in the parliament on Tuesday.
AB-PMJAY is the flagship health scheme of the central government which provides a health cover up to Rs 5 lakh per family per year, for secondary and tertiary care hospitalization services. The CAG has conducted an audit covering the period September 2018 t0 March 2021.

According to the report, data analysis of mortality cases revealed that 88,760 patients died during treatment specified under the scheme. However, a total of 2, 14,923 claims shown as paid in the system related to fresh treatment in respect of these patients.
Audit further noted that in 3,903 of above claims amounting to Rs 6.97 crore pertaining to 3,446 patients were paid to hospitals.
“The maximum number of such cases were observed in Chhattisgarh, Haryana, Jharkhand, Kerala and Madhya Pradesh and minimum number of cases were observed in Andaman and Nicobar Islands, Assam, Chandigarh, Manipur and Sikkim,” the report says.
The National Health Authority (NHA), the apex body responsible for implementing AB-PMJAY, clarified to the CAG that back-date of admission was allowed in the system for various operational reasons but the auditor held the explanation as not tenable and recommended that the national and the state health authorities should ensure a comprehensive investigation of all cases to obviate the risk of irregular payment and malfeasance.
AB-PMJAY provides a cover of Rs 5 lakh per family per year for secondary and tertiary care hospitalization across public and private empanelled hospitals in India. Out-patient care/treatment is, however, not covered under the scheme.
The CAG audit revealed that the IT system (TMS) did not prevent any patient from getting admission in multiple hospitals during the same period of hospitalizations.
NHA, while acknowledging the lapse, stated (July 2020) that primarily these cases arise in scenarios where a baby is born in one hospital and shifted to neonatal care in another hospital using PMJAY ID of mother. However, according to the report, illustrative data analysis revealed that 78,396 claims of 48,387 patients were initiated in TMS where date of discharge of these patients for earlier treatment was later than admission date for another treatment of the same patient.
Contrary to the claim of NHA, these patients included 23,670 male patients. These claims pertained to 2,231 distinct hospitals, the CAG report says.
“Highest number of cases were noted in the States such as Chhattisgarh, Gujarat, Kerala, Madhya Pradesh and Punjab and lowest number of cases were noted in Daman and Diu, Goa, Karnataka, Puducherry and Tamil Nadu. Successful payment of such claims further indicates lapses on part of SHAs in processing the claims without even verifying the requisite checks therein,” the audit points out.
The CAG report on performance of AB-PMJAY also shows that though beneficiaries in Bihar and Uttar Pradesh are numerous at 5.56 crore and 6.47 crore, availability of empanelled health facilities in these states was very low in comparison at 1.8 and 5 Empanelled Healthcare Provider (EHCPs) respectively to a lakh of population. Other states/UTs with less empanelled hospitals are Assam (3.4), Dadra Nagar Haveli-Daman Diu (3.6), Maharashtra (3) and Rajasthan (3.8). The report also points to deficiencies such as the absence of adequate validation controls leading to ineligible beneficiaries getting enrolled. Many state government pensioners have been added to the beneficiary list, according to the CAG report.