NEW DELHI: The rapidly increasing popularity of the government’s flagship health insurance scheme Ayushman Bharat has also made it equally vulnerable to frauds. This has prompted the government to put in put in place extra layers of protection by using artificial intelligence , monitoring utilisation trends, and forming standard treatment protocols to check irregularities including overcharging, wrong billing, over testing, beneficiary duplication and abuse in referral mechanism.

While 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 detecting potential fraud cases and conducting detailed investigation before taking action.

The NHA has issued show-cause notices to 48 hospitals across the country so far, out of which 31 hospitals have been suspended following detailed investigation, a senior official said.

“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 claimed falsely by the hospitals and additional penalties have also been imposed as per the anti-fraud guidelines,” the official said.

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 illegally issuing referral slips for a private hospital in return for pecuniary benefits.

In another such case, the anti-fraud wing of the agency observed the treating doctor in a public hospital was referring the case to his own private clinic even as there was no specialist available to treat the patient in the private clinic.

“These cases were detected because of strict gatekeeping. We investigated these cases without any delay and disciplinary action was initiated immediately,” another official said.

Fraud cases also include billing of services not provided or wrong coding of packages to charge a higher amount etc.

To keep a check on such tendencies of hospitals to overcharge and other related issues, NHA has introduced all-inclusive package rates.

Hospitals were also found abusing the pre-authorisation norm, which is actually meant to keep a check on claims. The pre-authorisation needs to be approved within six hours of admitting and treating patients under the scheme and if the authority concerned does not approve within six hours, it is deemed to be approved .

Some hospitals were found initiating the process late at night when there would be no one to approve.

To address this loophole, now regular requests are being entertained only between 10 am and 5 pm. At other times, only emergencies will be looked into.

Besides, all pre-authorisation and claims transactions are carried out on-line basis for efficiency and complete transparency.

NHA has also designed IT systems and processes with checks and balances for all processes – beneficiary identification, transaction management system, funds flow, claims payment etc.

NHA maintains it is walking a tightrope to strengthen the system by tightening the noose around private hospitals and insurance companies while ensuring a smooth access of health care services for beneficiaries of the scheme.

