IPA Newspack
  • Home
  • now
  • politics
  • business
  • markets

IPA /

IPA Special

IPA Special

PM-JAY Scheme Is Infested With Frauds And Abuses

By Dr. Gyan Pathak

Pradhan Mantri Jan Arogya Yojana (PM-JAY) is infested with frauds and abuses. Different kinds of frauds are being encountered, both in relation to the making of e-cards for beneficiaries and also the provisions of treatment by hospitals. Corruption in India’s National Health Insurance Scheme Ayusman Bharat scheme seems to be rampant.

An ADB study titled “Social Protection in pandemic – trends, challenges & technology” has also found that corruption in the scheme is a major concern for social and health security in India, which is presently world’s second-most populous country with 1.4 billion inhabitants in 2021. It is a lower middle income country with a per capita GNI of USD 1,900 in 2020 containing a large number of extremely poor people.

The government of India has created and runs a variety of social protection programmes in the country, such as subsidized food and public works programmes, under which anyone can theoretically find work for modest pay, take a prominent position among these, etc, but practically there seems to be different story altogether, if what is happening in PM-JAY is of any indication.

The case study titled “Assessment/Management: Anti-Fraud System for India’s National Health Insurance Scheme” says that the National Health Insurance Scheme, ‘PM-JAY’, is the world’s largest publicly-funded health insurance scheme, covering around 650 million people in 130 million households in 2020, which is nearly half the population. Participating families are entitled to a cashless service of up to Indian rupees (INR) 500,000 (USD 6,700) in annual hospitalisation expenses. There are no eligibility exclusions in terms of age or family size and pre-existing conditions are also covered. Treatment is available nationwide in more than 24,000 ‘empanelled’ hospitals, which are authorised to provide cashless treatment.

However, as with any health insurance scheme, PM-JAY is not untouched by fraud and abuse issues. As the scheme grows, different kinds of fraud are being encountered, both in relation to the making of e-cards for beneficiaries and also the provision of treatment by hospitals, the case study says. With the increase in number of claims and experience gained by hospitals, there have been cases of provider induced fraud and abuse.

Fraud deterrence is a major concern for health insurance at the best of times, but the opportunity to exploit the system expands during crises, such as during the pandemic in April 2021, when the number of people requiring hospital treatment started rising extremely quickly, ultimately overwhelming the capacity of the health system to provide treatment.

Though the study has mentioned several measures taken by the Government of India, including deployment of AI tools, the study has mentioned systematic fraud, in which a group of persons collude, as a major risk, as it can lead to high volumes of fraudulent transactions. One example of coordinated fraud is the repeated use of authentic and, therefore, plausible referral and claim documents in a number of hospitals spread across different Indian states.

The study mentioned automated tools deployed to monitor and detect suspicious activities, but it warns that it can still only provide clues and leads that human operators then need to follow up. Instead of fully automated fraud detection, a large part of the utility lies in freeing human resources from repetitive tasks to focus on case audits. The evidence from 2020 suggested that a large percentage of registrants flagged for further investigation were indeed found to be fraudulent.

While referring to technological solutions, the study says, if the deterrence does not work and somebody tries to cheat the system, then it should be caught quickly with help of IT systems. Lastly, strict and swift action needs to be taken against those engaged in fraudulent activities, as there is extensive scope for fraud in health insurance (which may involve actors at the beneficiary, hospital and system administration levels, who may be engaging in a range of rackets. (IPA Service)

Politics

Victory of Bal Thackeray’s Hindutva, claims Shinde

June 27, 2022
Happening Now

Key Uddhav aide Raut summoned by ED for ‘money laundering’

June 27, 2022
IPA Special

There Is Little To Justify India’s Coal Shortage

June 27, 2022
IPA Special

Central Trade Unions Get Ready To Fight New Rules For Workers

June 27, 2022
IPA Special

Right-Wing Takeover In Andalusia Is A Setback To Spain’s Coalition Govt

June 27, 2022
IPA Special

Fear And Sycophancy Stalking Present India Under BJP Regime

June 27, 2022
IPA Special

Akhilesh Failed To Give Proper Leadership In Campaign For Bypolls

June 27, 2022
IPA Special

In Power Battle In Maharashtra, Ideology And Dynasty Are In Collision

June 27, 2022
IPA Special

India’s Neighbouring Economies Are Facing Severe Balance Of Payments Crisis

June 27, 2022
Politics

Owaisi hits out at Akhilesh after SP’s loss to BJP

June 27, 2022
Happening Now

Radisson Guwahati closes all bookings till June 30

June 27, 2022
Politics

Simranjit Mann credits Sangrur win to Bhindranwale

June 27, 2022
Politics

Rumblings in AIADMK grow as EPS camp convenes meet

June 27, 2022
Happening Now

Eknath Shinde has late night meeting with Fadnavis

June 26, 2022
Happening Now

Rajasthan anti-corruption body notice to Union minister

June 26, 2022
Happening Now

Cong raises points about SC clean chit to Modi

June 26, 2022
Happening Now

Gujarat ex top cop, activist held within a day of SC verdict

June 26, 2022
Happening Now

Ram Gopal Varma in trouble over tweet on Droupadi Murmu

June 26, 2022
IPA Special

Droupadi Murmu Is All Set To Become The Next President Of India

June 25, 2022
IPA Special

Battle Lines Are Drawn In Maharashtra But For Uddhav, It Is Really Tough

June 25, 2022

An appeal

The legacy of IPA, founded by Nikhil Chakravartty, the doyen of journalism in India, to keep the flag of independent media flying high, is facing the threat of extinction due to the effect of the Covid pandemic. Only an emergency funding can avert such an eventuality. We appeal to all those who believe in the freedom of expression to contribute to this noble cause.
Click here to learn more

Share

Reply

  • 0
More on IPA

There Is Little To Justify India’s Coal Shortage

June 27, 2022 3:15 pm | IPA Staff

By Nantoo Banerjee It is a matter of concern that India, sitting over the world’s fifth largest proven coal reserves of well over 111 billion...

IPA Special

Central Trade Unions Get Ready To Fight New Rules For Workers

June 27, 2022 3:13 pm | IPA Staff

By Dr. Gyan Pathak Had the Modi Government not been undergoing some fresh resistance from the unemployed youths for yet another disastrous policy experiment in...

IPA Special

Right-Wing Takeover In Andalusia Is A Setback To Spain’s Coalition Govt

June 27, 2022 1:45 pm | IPA Staff

By Eoghan Gilmartin “A very hard blow.” Spanish prime minister Pedro Sánchez couldn’t mask his disappointment at the resounding defeat for his Socialist Party (PSOE)...

IPA Special

Fear And Sycophancy Stalking Present India Under BJP Regime

June 27, 2022 12:08 pm | IPA Staff

By Amulya Ganguli A feature of the present ruling dispensation at the centre is the fear that it has generated even among the rich and...

IPA Special

There Is Little To Justify India’s Coal Shortage

in IPA Special
Jun 27, 2022   ·  

Central Trade Unions Get Ready To Fight New Rules For Workers

in IPA Special
Jun 27, 2022   ·  

Right-Wing Takeover In Andalusia Is A Setback To Spain’s Coalition Govt

in IPA Special
Jun 27, 2022   ·  

Leave a Reply Cancel reply

You must be logged in to post a comment.

Follow us on
Up Next: Our Prime Minister Is A Fixer In Chief In The Country For Every Vexed Issue
©2020 -2021 India Press Agency, All Rights Reserved
Newspack by India Press Agency
Posting....
logo
  • Home
  • now
  • politics
  • business
  • markets