The popularity of the government’s flagship health insurance scheme Ayushman Bharat has been rapidly increasing and is equally vulnerable to frauds. Due to this, the government has to put in place extra layers of protection by using artificial intelligence (AI), monitoring utilisation trends, and forming standard treatment protocols to check irregularities which includes overcharging, wrong billing, over testing, beneficiary duplication and abuse in referral mechanism.

Till date, the scheme has touched almost 30 lakh beneficiaries within 10 months of its launch in September last year. The anti-fraud unit of the National Health Authority (NHA) - the government’s implementing agency for the scheme – is proactively distinguishing possible fraud cases and conducting detailed investigation before taking any action.

A senior official said that, the NHA has issued show-cause notices to 48 hospitals across the country out of which 31 hospitals have been suspended following a detailed investigation. The official also said that for three such cases that were confirmed as fraud, first information report (FIRs) have been filed by the State Anti Fraud Unit and they have been de-empanelled already. Action has been initiated to recover the amount which was claimed falsely by the hospitals and added penalties have been imposed as per the anti-fraud guidelines.

The irregularities detected by the anti-fraud wing of NHA includes cases like abuse of referral mechanism in a few hospitals where doctors in certain public hospitals were unlawfully issuing referral slips for a private hospital in return for financial benefits. In one more such case, the anti-fraud wing of the agency observed that the treating doctor in a public hospital was referring the case to his own private clinic even though there was no specialist available to treat the patient in the private clinic.

Another official said that such cases were detected because of strict gate keeping and were investigated without any delay and disciplinary action was taken immediately. Fraud cases can also include billing of services which were not provided or wrong coding of packages to charge a higher amount etc. To keep a check on such cases of hospitals overcharging and other related issues, NHA has introduced all-inclusive package rates.

Hospitals often abuse the pre-authorisation norm, which is meant to keep a check on claims. The pre-authorisation has to be approved within six hours of admitting and treating patients under the scheme and if the concerned authority does not approve within six hours, it is believed to be approved. Few hospitals were found initiating the process late at night when there is no one to approve.

To deal with this loophole, regular requests are being entertained only between 10 am and 5 pm. At other times, only emergencies will be taken into consideration. All pre-authorisation and claims transactions are carried out on-line basis for effectiveness and complete transparency.

NHA has designed IT systems and processes with checks and balances for all processes – beneficiary identification, transaction management system, funds flow, claims payment etc. NHA also maintains walking on a tightrope to strengthen the system by tightening the noose around private hospitals and insurance companies and ensuring a smooth access of health care services for beneficiaries of the scheme.