PMJAY Fraud: Gujarat to introduce new SOPs for private hospitals
Ahmedabad: The Gujarat government
has imposed a ban on free medical camps across the state following the deaths of two Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) beneficiaries at a hospital after a botched angioplasty. The step is part of an overarching initiative to crack down on fraud practices under the PM-JAY scheme which provides health insurance to millions of citizens.
With a significant
resource allocated for implementing PM-JAY in Gujarat, there will be a
digitalization initiative undertaken by the SHA (State Health Agency) to
increase transparency and efficiency. Drawing inspiration from the Delhi Health Department, the SHA plans to develop an artificial intelligence-enabled portal
designed to quickly identify fake or non-compliant documents, reports The Federal.
As part of the new
measures, which will include a Standard Operating Procedure (SOP) for private
hospitals linked to the PM-JAY scheme, the details were shared during a meeting
held in Gandhinagar with Health Minister Rushikesh Patel and top officials. The
four departments including cardiology, oncology, paediatrics, and orthopaedic
surgery are considered the most misused categories as they allow the maximum
amount of insurance under the PMJAY-MA scheme. The State Health Agency data
shows the most common operations performed under the scheme are knee
replacements and cardiac procedures — also the most susceptible to fraudulent
claims. A two-tier scrutiny mechanism will be put in place under the new SOP.
“While the Union
government gives up to Rs 5 lakh for cases in these specialities, the Gujarat
government assures an additional amount up to Rs 10 lakh under the Maa Amrutam
Yojna,” he said. “We have identified the loopholes in the current system, which
will be replaced with a strict SOP to ensure that provisions of PMJAY are not
misused,” Patel said.
Once a doctor recommends
surgery, a small group of SHA doctors will review the recommendation before
final approval. TBCs (Tumor Board Certificates) for oncology will also be
mandated with an online portal to facilitate this process. To enhance oversight
further, the SHA will require all hospitals that are empaneled under the scheme
to use the Clinical Establishment Act. The formation of State Anti-Fraud Units
(SAFU) will facilitate surprise inspections by dev teams at the district and
state levels during the entire year.
Since the scheme was
launched 5 years ago, the SHA has been manually managing the PM-JAY operations
and monitoring over 36 crore Ayushman cards and as many as nearly 7 crore
hospital admissions. But after the recent deaths of two patients at Khyati
Multi Specialty Hospital, a thorough investigation was launched. Already, the
licenses of 12 doctors named in these fraudulent activities were canceled by
the Gujarat Medical Council.
Four hospitals, including
Krishna Surgical Hospital and Swastik Multispeciality Hospitals, have been
debarred from the PM-JAY scheme so far as part of the action, taking the total
number of penalized hospitals to 16. Investigations are ongoing, with the Crime
Branch also involved in the probe.
