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National Health Scheme: Focus on System to Check Fraud

Dedicated fraud detection cells in every state and at the national level, 100 percent death audits and advanced data analytics — these are some of the elements of the zero-tolerance policy for fraud in the Pradhan Mantri Jan Arogya Yojana (PMJAY). The National Health Agency (NHA), which is the implementing authority for the ₹5 lakh health assurance/insurance scheme, has drawn up elaborate guidelines for fraud detection. It is also in talks with some of the world’s biggest data analytics companies like IQVIA, LexisNexis, Optum (UHL), IrisTech and SAS for a proof of concept for a system for fraud prevention, detection and deterrence. The companies have offered to provide the proof of concept design pro bono, and, based on those designs, the NHA will call for a global tender. The guidelines have already been sent to the states.

“The Prime Minister, in all our meetings, discussed fraud in great detail. In fact, he stressed on how the fraud detection guidelines and mechanisms would constantly need to be updated so that the system stays one step ahead all the time. He knows what happens on the ground more than anybody. Preventing fraud is also very important for maintaining the political support for the scheme,” said NHA CEO Dr Indu Bhushan. The proof of concept submitted by the five companies would play a key role in deciding the final contours of the fraud detection system. “We will soon be inviting the top analytics and artificial intelligence companies for fraud detection and prevention systems. These companies have already approached NHA for a proof of concept,” said Deputy CEO Dr Dinesh Arora.

The guidelines that categorize fraud at three levels — beneficiary fraud, payer (trust or insurance company) fraud and provider (hospital) fraud — lay down eight situations that would constitute fraud under PMJAY. These are impersonation, counterfeiting, misappropriation, criminal breach of trust, cheating, forgery, falsification and concealment. The guidelines talk of developing “data standards and guidelines for data consolidation, mining and advanced analytics using predictive modelling, machine-learning models, regression techniques and social network analysis. Over a period of time, the NHA may integrate artificial intelligence and machine learning algorithms into the IT system for state-of-art fraud detection platform.” Health Minister JP Nadda said on Monday that when the scheme rolls out on September 25, every beneficiary family will receive a letter with a QR code that will be used for verification. There is no system of enrolment for the program. – Indian Express


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