10th August 2023 (6 Topics)
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CAG audit exposes multiple frauds in PMJAY
Context
As per the audit findings released by Comptroller and Auditor General (CAG), multiple cases of the Ayushman Bharat-Pradhan Mantri Jan ArogyaYojana (PMJAY)has been found providing treatment for patients who had already been declared dead, as well as for thousands of people using the same Aadhaar number or invalid mobile phone number.
About
Findings from the Audit:
- Due to the absence of adequate validation controls, errors were noticed in beneficiary databases, such as invalid names, unrealistic date of birth, duplicate PMJAY IDs, and unrealistic size of family members in a household.
- Patients earlier shown as ‘dead’ continued to avail treatment under the scheme.
- The maximum number of such cases was in Chhattisgarh, Haryana, Jharkhand, Kerala and Madhya Pradesh.
- The minimum number of such cases was observed in the Andaman & Nicobar Islands, Assam, Chandigarh, Manipur and Sikkim.
- Penalties amounting to Rs.12.32 crore from 100 hospitals were pending in nine States.
- In Andhra Pradesh and Punjab, private hospitals were performing procedures reserved for public hospitals.
About Ayushman Bharat-Pradhan Mantri Jan ArogyaYojana (PMJAY):
- PM-JAY is the world’s largest health insurance/ assurance scheme fully financed by the government.
- Launched in February 2018, it offers a sum insured of 5 lakh per family for secondary care (which doesn’t involve a super specialist) as well as tertiary care (which involves a super specialist).
- Under PMJAY, cashless and paperless access to services is provided to the beneficiaries at the point of service, that is, hospital.
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Nodal Agency:
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- Health Benefit Packages covers surgery, medical and day care treatments, cost of medicines and diagnostics.
- Packaged rates (Rates that include everything so that each product or service is not charged for separately).
- Funding pattern: The funding for the scheme is shared – 60:40 for all states and UTs with their own legislature, 90:10 in Northeast states and Jammu and Kashmir, Himachal and Uttarakhand and 100% Central funding for UTs without legislature.
Identification of beneficiaries
- AB-PMJAY identifies the beneficiary through Aadhaar identification wherein the beneficiary undergoes the process of mandatory Aadhaar based e-KYC.
- The details fetched from the Aadhaar database are matched with the source database and accordingly, the request for Ayushman card is approved or rejected based on the beneficiary details.
- The scheme only used mobile numbers to reach out to the beneficiaries in case of any need and for collecting feedback regarding the treatment, rather than for any verification purposes.
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