Massive Penalties Imposed on Hospitals in Ayushman Bharat Scam
Summary: The Ayushman Bharat–Pradhan Mantri Jan Arogya Yojana has taken strict action against fraudulent practices, with over 1,100 hospitals de-empanelled, 1,500 penalized, and 549 suspended. A strong grievance redressal system and timely claim settlement measures aim to ensure accountability and protect beneficiaries.
The Ayushman Bharat Health Insurance scheme laid down under the aegis of the Ayushman Bharat- Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) have seen cases of fraudulent claims which have led to the de-empanelment of 1,114 hospitals; imposition of penalty of about 122 crores on 1,504 hospitals and 549 hospitals have been suspended, as per a report, relating to all the states and Union Territories, given in the Lok Sabha.
The Ayushman Bharat- Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) has been formed and “is governed on a zero-tolerance policy towards misuse and abuse”, replied Prataprao Jadhav – the Minister of State for Health and Family Welfare. He also stated that the necessary steps have been taken for “prevention, detection and deterrence of different kinds of irregularities that could occur in the scheme at different stages of its implementation”.
Corrective Actions Against Fraudulent Practices
He added that this corrective action includes the de-empanelment of 1,114 hospitals; imposition of penalty of about 122 crores on 1,504 hospitals and 549 hospitals have been suspended. The terms and conditions of empanelment require that no eligible beneficiary under the AB-PMJAY scheme should be denied treatment. If a beneficiary is denied treatment, they are within their rights to lodge a complaint against the erring hospital.
Grievance Redressal and Claim Settlement
In the event any beneficiary faces hurdles in getting the relevant treatment, there is a provision, a three-tier grievance redressal system, on district, state and national levels, to address such complaints. Each level has its specific officers for addressal of such grievances. Complaints can be filed, by the beneficiaries, via web-based portal, the Centralised Grievance Redressal Management System (CGRMS), e-mail, or letter written to the State Health Agencies (SHA-s) among others. The corrective action, based on the nature of the complaint, and support to the beneficiary is then taken.
The SHA-s settle the claims corresponding to their respective areas, as per the AB-PMJAY. According to the guidelines laid down by the NHA, payment of claims, to the hospitals within the state, is to be made within a period of 15 days of receiving such claim. Whereas in case of hospitals situated outside the state, portable claims should be settled in 30 days. Timely settlement of claims being of utmost importance.
The average turnaround time (TAT) for timely settlement has notably improved over the years. There are regular reviews undertaken to check on the progress of the claims and capacity-building activities are also carried out for the efficient settlement of claims, said the Minister.
