Recent media reports have circulated claims that the Comptroller and Auditor General of India (CAG) raised concerns regarding the Ayushman Bharat Pradhan Mantri – Jan Arogya Yojana (AB PM-JAY). These reports suggest that treatments were booked for AB PM-JAY beneficiaries who had been declared deceased in the system, and that some beneficiaries were found to be receiving treatment at two different hospitals simultaneously. However, it is essential to clarify that these reports are misleading and lack accurate information.
The CAG’s report on the Performance Audit of AB PM-JAY, covering the period from September 2018 to March 2021, was presented in the Parliament during the Monsoon Session of 2023.
Clarification on Deceased Beneficiaries:
Under AB PM-JAY, hospitals have the option to initiate pre-authorization requests up to three days after a patient’s admission. This flexibility is designed to prevent treatment denial in cases of limited connectivity or emergencies.
In some instances, patients were admitted and received treatment before the pre-authorization request was raised. Unfortunately, some of these patients passed away during treatment, resulting in the date of death matching the admission date or occurring earlier. Notably, the same hospital that raised the pre-authorization request also reported the patient’s death. This clearly demonstrates that hospitals did not intend to defraud the system.
More than 50% of the cases highlighted in the report were initiated by public hospitals, which have no incentive to commit fraud, as funds are reimbursed directly to their accounts. Additionally, hospitals are obligated to submit a mortality report in case of a patient’s death during treatment.
Explanation of Multiple Hospital Use:
AB PM-JAY allows children up to five years of age to receive treatment under the Ayushman Card of their parents. Consequently, an Ayushman Card can be used simultaneously for children and either parent in different hospitals. For example, a mother might be admitted to a hospital, where she subsequently gives birth. If the hospital lacks neonatal care facilities, the baby might be transferred to another hospital with the necessary facilities. In this scenario, the mother’s Ayushman Card covers both the mother and child.
Often, when the child passes away during treatment, the hospital erroneously registers the child’s death against the mother’s card. Subsequently, when the mother seeks further treatment, she is denied services due to the child’s death marker. In such cases, grievances are raised, and the marker is removed from the mother’s card.
AB PM-JAY employs a robust four-step claim processing system that scrutinizes hospital claims at every stage. Defined triggers identify cases for further examination, which may include desk and field audits. Hospitals found engaging in fraud or abuse face penalties, including de-empanelment.
Role of Mobile Numbers:
The CAG report mentions the use of the same mobile number by multiple beneficiaries. However, mobile numbers are not mandatory for beneficiary verification under AB PM-JAY. The beneficiary identification process relies on Aadhaar identification, with mandatory Aadhaar-based e-KYC. Mobile numbers are primarily used for outreach and feedback collection, not for beneficiary verification.
AB PM-JAY serves a beneficiary base where many may not possess mobile numbers or have frequently changing numbers. Additional verification options, such as fingerprint, iris scan, and face-auth, are provided, with fingerprint-based authentication being the most common.
In conclusion, the treatment of beneficiaries cannot be withheld based solely on the absence of a valid mobile number, as mobile numbers have a limited role in the treatment workflow. The scheme is entitlement-based, not enrolment-based, with a fixed beneficiary database. Necessary actions have been taken to capture only valid mobile numbers in the current IT portal.
The National Health Authority and the Ministry of Health & Family Welfare are closely examining the CAG’s recommendations and are committed to strengthening the IT platform and processes to enhance the efficiency and effectiveness of AB PM-JAY.