The Gujarat government is taking strong steps to tackle fraudulent practices under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY), a health insurance scheme that provides coverage to millions of citizens. This comes after the unfortunate deaths of two PM-JAY beneficiaries at a hospital following a botched angioplasty.
To address these issues, the government has banned free medical camps and introduced new Standard Operating Procedures (SOPs) for private hospitals linked to PM-JAY.
Why Are These Changes Being Made?
Since its launch five years ago, the PM-JAY scheme has faced several challenges, including fraudulent claims. Departments such as cardiology, oncology, pediatrics, and orthopedic surgery have been identified as the most misused categories under the scheme, as they allow for the maximum insurance claims.
For example:
- Knee replacements and cardiac procedures are among the most common operations under PM-JAY but are also the most prone to fraud.
- The Gujarat government provides additional insurance coverage of up to ₹10 lakh under the Maa Amrutam Yojna, increasing the risk of misuse.
New Initiatives to Prevent Fraud
To improve transparency and efficiency, the State Health Agency (SHA) has outlined several key measures:
- Digitalization Initiative:
Inspired by the Delhi Health Department, an AI-enabled portal will be developed to detect fake or non-compliant documents quickly. - Two-Tier Scrutiny:
- Once a doctor recommends surgery, a small group of SHA doctors will review the recommendation before final approval.
- Tumor Board Certificates (TBCs) will be mandated for oncology cases, with an online system to streamline the process.
- Mandatory Use of Clinical Establishment Act:
All hospitals under the PM-JAY scheme will now be required to comply with the Clinical Establishment Act to ensure accountability and standardization. - State Anti-Fraud Units (SAFU):
Special units will conduct surprise inspections at district and state levels throughout the year to monitor compliance and detect fraud.
Action Taken So Far
The government has already taken several steps against fraudulent practices:
- Licenses of 12 doctors involved in fraudulent activities have been canceled by the Gujarat Medical Council.
- 16 hospitals, including Krishna Surgical Hospital and Swastik Multispeciality Hospitals, have been penalized or debarred from the PM-JAY scheme.
- Investigations are ongoing, with the Crime Branch actively involved.
Strengthening Oversight
To enhance monitoring, the SHA is now managing over 36 crore Ayushman cards and nearly 7 crore hospital admissions digitally. These measures aim to replace loopholes in the current system with strict guidelines, ensuring that PM-JAY provisions are not misused.
Impact on Healthcare
These reforms are expected to:
- Enhance patient safety and trust in the PM-JAY scheme.
- Reduce fraudulent claims, ensuring that funds are used for genuine cases.
- Improve the efficiency of private hospitals by adhering to strict SOPs.
Conclusion
The Gujarat government’s crackdown on PM-JAY fraud is a step in the right direction to protect patients and improve healthcare transparency. With initiatives like AI-enabled portals, stricter SOPs, and surprise inspections, these measures aim to ensure that health insurance benefits reach the right people.
As healthcare professionals, it’s crucial to support these efforts and maintain the integrity of such schemes to improve patient outcomes and uphold trust in the medical community.
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