The report by the Comptroller and Auditor General of India (CAG) revealed that a large number of patients earlier shown as dead continued to grant treatment under the Ayushman Bharat-Pradhan Mantri Jan Aarogya Yojana (AB-PMJAY). Chhattisgarh, Haryana, Jharkhand, Kerala and Madhya Pradesh reported the maximum number of these fraud cases.

The report stated, “Data analysis of mortality cases in TMS revealed that 88,760 patients died during treatment specified under the scheme. A total of 2,14,923 claims are shown as paid in the system, related to fresh treatment for these patients. The audit further commented that 3,903 of the above claims amounting to ₹ 6.97 crores pertaining to 3,446 patients were paid to hospitals.”

Further data analysis revealed that the same patient could get admission to multiple hospitals during the same period of hospitalisation. Moreover, the report noted no mechanism to prevent any patient from gaining admission to different hospitals during the same period of hospitalisation.

Earlier in July 2020, the National Health Authority (NHA) had already acknowledged this case and mentioned that such issues arise when a baby is born in one hospital and shifted for neo-natal care in another hospital using the PMJAY ID of the mother. Meanwhile, the data analysis by CAG opposes this explanation of NHA and found out that 78,396 claims of 48,387 patients were initiated in the database wherein the date of discharge of these patients for earlier treatment was later than the admission date for another treatment of the same patient.

These patients included 23,670 male patients. Such cases were more prevalent in Chhattisgarh, Gujarat, Kerala, Madhya Pradesh and Punjab. The report noted, “Successful payment of such claims further indicates lapses on the part of state health agencies (SHAs) in processing the claims without even verifying the requisite checks.”

The NHA mentioned earlier that the issue was because of non-synchronisation of the date and time of the computers, cases of neo-natal babies, and recording of pre-authorisation after the date of admission.

Tackling the issue with AI & ML

The MoS Health and Family Welfare SP Singh Bhaghel informed the Rajya Sabha through a written reply that the Government of India uses Artificial Intelligence and Machine Learning to spot suspicious transactions and the potential fraud risks under the AB-PMJAY scheme.

These technologies are reportedly used for detecting and preventing healthcare fraud while the scheme is implemented. It aids in ensuring appropriate treatment for the eligible beneficiaries. The technology partners are involved in developing and deploying anti-fraud measures by harnessing the power of AL/ML. As per the report on 1 August 2023, a total number of 23.33 crore Ayushman cards were created under the scheme.