A total of 171 hospitals have been de-empanelled and penalties to the tune of Rs 4.5 crore have been imposed on hospitals for allegedly committed fraud and indulging in malpractices under the Ayushman Bharat health insurance scheme, the apex body implementing it said on Friday. FIRs have been lodged against six hospitals in Uttarakhand and Jharkhand, the National Health Authority said.
The NHA said the National Anti-Fraud Unit has detected suspect e-cards on the basis of algorithms developed internally by it and shared with states for due diligence and action.
It ruled out any possibility of a fake e-card being generated automatically by the system, saying the process requires a go-ahead by authorised persons based on supporting documents and final approval of the state health agency officials to not just create an e-card but also to add any additional family member.
"171 are already de-empanelled and the list of these hospitals is posted on PMJAY website http://www.pmjay.gov.in/de-empanelled. Penalties to the tune of more than INR 4.5 crore have also been levied on hospitals indulging in malpractices," the NHA said in a statement.
The cover provided under PM-JAY is Rs 5 lakh per family and not Rs 5 lakh per e-card. There is no package under the PM-JAY scheme which is free for the government. There are certain packages, especially abuse-prone packages, which are reserved for government hospitals by the state authorities, it said.
It was detected that private hospitals were performing these government reserved procedures and blocking/submitting the same under a different package name or as an unspecified package.
According to the statement, cases of fraud were detected by NAFU in August 2019 and shared with the Gujarat State Health agency which has disabled the cards and an FIR was lodged on November 8.
In Chhattisgarh, such cases were detected initially in May 2019 and the cards have been disabled.
In Madhya Pradesh, cases were detected in August 2019 and shared with the state which has disabled the cards and the concerned hospital has been issued a show-cause notice. The penalty has also been levied on TPA.
The cases in Punjab were detected in Oct 2019 and shared with the state which has disabled the cards.