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17th July 2023 (8 Topics)

AI helps tackle fraud under AB-PMJAY

Context

According to data with the Health Ministry, a penalty amount of Rs.9.5 crore has been recovered based on information of fraud obtained through artificial intelligence and machine learning-based anti-fraud initiative protecting the world’s largest government-run insurance scheme Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY).

  • Also about 3 lakh Ayushman cards have been disabled and 210 hospitals de-empanelled.

About the guidelines:

  • Around 18% of the total authorised hospital admissions under the scheme have also been confirmed as fraud since its inception.
  • Additionally, 188 hospitals have been suspended and a penalty of Rs.20.17 crore levied across board as part of the anti-fraud drive. 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.
  • The scheme is governed by a zero-tolerance approach to any kind of fraud viz. suspect/non-genuine medical treatment claims, impersonation, and up-coding of treatment packages/procedures etc.

The government is now pushing for Ayushman card saturation — where of the existing cards more than 40% were created in the last financial year (2022-23) — deployment of health kiosks, timely settlement of claims, empanel and activate hospitals and increase scheme uptake.

Future Aspirations:

  • The government is now working at;
    • developing and strengthening health and wellness centres,
    • Blocking public health units,
    • Expanding disease surveillance systems, and
    • Strengthen pandemic research and a multi-sector national institutions platform.

What is artificial intelligence (AI) governance?

  • Artificial intelligence governance is the legal framework for ensuring AI and machine learning technologies are researched and developed with the goal of helping humanity navigate the adoption and use of these systems in ethical and responsible ways.
  • AI governance aims to close the gap that exists between accountability and ethics in technological advancement.
  • AI use is rapidly increasing across nearly all industry sectors, including healthcare, transportation, retail, financial services, education and public safety.
  • As a result, governance has taken on a more significant role and is getting more attention than in the past.

How AI can help in Governance model in India?

  • AI can be used to assist members of the public to interact with government and access government services.
  • It is the most effective technique of eliminating corruption by automating services and guaranteeing transparency in information communicated and making it easily available to the public.
  • Ease of access to government services for all citizens 24*7 via online applications.

Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY):

  • The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) SEHAT scheme would work in convergence with Pradhan Mantri Jan Arogya Yojana(PM-JAY)
  • Beneficiaries: All residents of India, irrespective of their socio-economic status, will be covered under the scheme.
    • The beneficiaries will get the Universal Healthcare Coverage (UHC) as per the SECC 2011 database.
  • The PM-JAY is world’s largest health insurance/assurance scheme fully financed by the government.
  • It provides a cover of Rs.500, 000 per family per year for secondary and tertiary care hospitalisation across public and private empanelled hospitals in India.

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