National Anti-Fraud Unit (NAFU) Detects Fraud and Abuse in Ayushman Bharat Scheme, Taking Action Against Claims Worth Rs 278 Crore
The National Health Authority (NHA) has established the National Anti-Fraud Unit (NAFU) to identify and prevent fraud and abuse within the Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) scheme, according to Union Health Minister Mansukh Mandaviya. In response to a question in the Lok Sabha regarding fraudulent transactions under AB-PMJAY, the minister noted that NAFU operates at the central level, with State Anti-Fraud Units (SAFUs) operating at the state level.
Mandaviya explained that NHA employs artificial intelligence (AI) and machine learning (ML) technologies to detect suspicious transactions and potential frauds under AB-PMJAY. These advanced technologies play a crucial role in preventing, detecting, and deterring healthcare frauds, ensuring that eligible beneficiaries receive appropriate treatment.
As of August 5, State Health Agencies (SHA) have taken appropriate actions against over 1.6 lakh claims worth Rs 278 crore, following guidelines issued by NHA. Additionally, 210 hospitals have been de-empanelled, and 188 hospitals have been suspended due to non-compliance with NHA or SHA guidelines. To address non-compliant activities, a penalty of Rs 20.71 crore has been imposed, with Rs 9.5 crore already recovered.
The AB-PMJAY, launched on September 23, 2018, provides health coverage up to Rs five lakh per family per year for secondary and tertiary care hospitalization services.
In a recent report presented to Parliament, the Comptroller and Auditor General of India (CAG) highlighted several irregularities in the implementation of AB-PMJAY.
While the NAFU’s efforts to detect fraud and abuse under the Ayushman Bharat scheme are commendable, it is essential to address the irregularities raised by the CAG report and ensure that the scheme operates smoothly. By employing technologies like AI and ML, the government can continue to enhance its ability to prevent fraudulent activities and guarantee the rightful utilization of healthcare resources.
It is crucial to maintain a balanced perspective on the Ayushman Bharat scheme and continuously work towards refining its implementation to maximize its impact on providing accessible and affordable healthcare to the citizens of India.
