With the idea of nipping in the bud any fraud in the ambitious Ayushman Bharat scheme, the national health authority is in talks with some leading data analytics companies including LexisNexis, Optum, SAS Institute, MFX and Greenojo to partner it in detecting such malpractices. While private sector is catering to over 60 percent of the beneficiaries under the scheme, there have been reports of spurt in certain procedures, or certain hospitals getting more number of patients than others. These companies will help detect such irregularities through software-based systems enabling the authority to keep a check, an official said. “These companies have developed different algorithms based on data that can trigger alerts for suspicious transactions. We are studying the different proposals in detail and will soon partner with them,” the official said. The government’s flagship health insurance scheme Pradhan Mantri Jan Arogya Yojana (PMJAY) under Ayushman Bharat aims to provide an annual cover of Rs 5 lakh to around 50 crore people in 10.74 crore deprived families.
So far, more than 11.51 lakh hospital admissions have been registered under the scheme, as per NHA data. Healthcare schemes are prone to fraud, abuse and leakages, which not only impacts the scheme but also entails risk to public health. Fraud detection mechanisms are common globally and NHA is also studying global best practices before finalizing a partnership pact. However, in India, though states do pre- and post-payment medical audits, there is no defined mechanism to detect fraud. NHA officials say prevention of fraud and abuse is critical for the success of the scheme and that there are clear cut instructions from the senior level of the government to take proactive fraud detection measures. The anti-fraud framework has also assumed significance because Aadhaar, the unique 12-digit identity number for residents of India, will be optional to avail of the benefits of the scheme and other identification cards will be accepted in the initial stages. To make the system fool proof, the Center is preparing personalized cards for beneficiaries it has identified, which need to be shown when treatment is sought in empanelled hospitals. The NHA has so far generated 1.47 crore gold cards. – TOI