Ayushman Bharat: How NHA is protecting patients from both sickness & fraud

The health authority is leaning on technology to catch cases of cheating, and is going beyond naming and shaming and rejecting claims, by imposing stiff penalities to stamp out the problem

Rolled out on September 23, the PMJAY (Prime Minister Jan Arogya Yojana) is a massive scheme covering 500 million Indian citizens, with special focus on the poorest of the country's poor. The first task of the scheme was to get the states to sign on. Starting with Uttar Pradesh, Chhattisgarh, Rajasthan and Madhya Pradesh, the yojana today embraces all states within the Union, save three -- Delhi, Telangana and Odisha. The National Health Authority (NHA) office at Jeevan Bharati building is abuzz with activity as the CEO, Dr Indu Bhushan, dwells on the nuts and bolts needed to strengthen PMJAY. 

In the two-and-a-half months since its launch, some 500,000 people benefitted from the scheme already. While currently more than 6,000 cases come in daily, Bhushan expects that number to grow to 20,000-25,000 soon. It is only then that the fault lines, if any, are likely to appear. Right now, the focus is on creating awareness, seeking out beneficiaries and informing them of the entitlement for their families. 

Fraud detection unit

One of the biggest and most significant tools that National Health Authority (NHA) is currently setting up is the fraud detection and malpractice control unit. Malti Jaiswal, executive director, comes with 30 years of experience in the health insurance sector. Jaiswal was CEO of a third-party insurance (TPA) company and her team is focused on weaving a net to catch cases of fraud. 

Right now, with 250,000 beneficiaries who have availed of benefits under PMJAY, the average amount which spent is Rs 16,000 per patient and the highest value surgery of Rs 200,000 has been dispersed. Total amount authorised as payout under the scheme till now is Rs 3 billion and rising. 

Health insurance companies have traditionally bled because of rampant fraud, which can occur at at any level. It could be initiated by any of the players in the three-way agreement -- the patient, the hospital or doctor and even the payer. 

Five steps to control malpractice

The e-card: "The NHA has a unique way of safeguarding identity theft. In the first instance, the Socio-Economic Cast Census (SECC) list has been verified by checking the intended beneficiaries' Aadhaar card and their mobile numbers have been getting updated since April this year. Eighty per cent of the data is so enriched,” says Jaiswal. While all SECC data may not be totally verified as yet, work is on continuously. 

For instance, a patient who goes to a hospital under the PMJAY umbrella will have a Kiosk manned by an Ayushman Mitra. This person will help with the verification by checking if the name of the patient appears on the data already fed into the bank of entitled individuals. The next level of verification will involve Aadhar card and biometrics (thumb impression). Based on this, the patient will get an e-card with a unique ID number. 

Whenever a beneficiary avails the PMJAY benefit, he will get a message about the money deducted from his wallet on mobile. If his identity is stolen or misused, he will be informed and he can then report the fraudulent transaction to Ayushman Mitra or State Health Authorities. 

The focus of PMJAY currently is on enrollment of beneficiaries. Fifty million silver cards have been issued and letters sent to beneficiaries to avail the facility or go to the nearest Common Service Centre (CSC) to get enrolled and get an e-card. A gold card with a barcode is subsequently issued by the CSC, hospital and even insurance company. While most states are offering an e-Card, some like Chhattisgarh, Assam, West Bengal and Rajasthan have issued a physical card as they upgrade from Rashtriya Swasthya Bima Yojana (RSBY). 

The card helps expedite pre-authorisation from the state as national portability is a crucial privilege and over 200 cases have already been done. “Tertiary care to a complex level is available in metros and patients cannot be denied that treatment. Secondary treatment can be had anywhere,” says Bhushan. 

The trust model: Many states have opted for the trust model of managing the money. So the administration will be done by the State Health Authority. “In an insurance model, chances of fraud are lower because insurers know how to play the game and would like to pay less. And if claim ratio is high, their profitability goes down. They are also professionally adept at spotting fraud,” Bhushan explains while agreeing that the incentive structure is not strong enough in a trust model, since it will be administered by a bureaucrat who may not have the skills to tackle fraud. The challenge will lie in building capacity to identify and catch frauds using the ID system, feedback from beneficiaries and social supervision. 

Only time will tell if the trust model works as well. RSBY did not allow the trust managed model, and the monetary part was completely managed by insurance companies.

Penal provisions: This time, though, the NHA will be taking a far stricter view. Hospitals found to be engaging in fraud and abuse will not just be named and shamed but struck off the panel.” Earlier there was no punitive action, just claim denial, so padding of costs, or misleading the patient by making them pay when the scheme is entirely free are some ways that hospitals/ doctors could cheat the patient,” says Jaiswal.

Some 14,561 hospitals are either in the process of being signed on, or are already in PMJAY's list. 

As a crucial part of the chain and as care providers, hospitals are responsible to set up partnerships with diagnostic and pharma companies. Ayushman Mitras are supposed to take a picture of the patient and give a daily report on the patient treatment, fill a case sheet, make daily notes on progress so that the hospital does not extend stay of the patient, and gives the correct treatment. 

Well-defined protocols: Healthcare in government hospitals is free, The hospitals will gain because they will be paid by the government for treatment given per patient. The treatment requires pre-authorisation which is time bound for the patient. Packages have been announced and some of the crucial ones have protocols defined for treatment so that the hospitals and doctors follow them and don't end up doing extra and unnecessary procedures that harm a patient. “while all diseases do not have treatment pathways which are defined, the process is on already,” says Jaiswal. Besides, states are identifying the list of packages prone to fraud, the most common being C-section, to be done only in government hospitals. In fact, Haryana, which has invested in upgrading its hospitals, has chosen 300 packages that will only be conducted in its own hospitals as otherwise, the investment it has done the past few years in public healthcare infrastructure will go waste. 

"We expect just about 1 per cent utilisation of the scheme,” adds Jaiswal. This means that for every 1,000 people insured, only 1 per cent will come for treatment.

Managing claims: The fourth level of checks will come in when claim submission is done. All documents will be checked, photo identity reviewed and verified, pre-authorization checked based on the discharge summary and only then will the claim be processed. Ensuring documents are complete is also the job of the Ayushman Mitra who is the face of PMJAY in the hospital. Approving doctor at the pre-authorization level can trigger an investigation as well. 

“Over and above all the information, we have artificial intelligence built in on pre-authorization, our system will be scanning for symptoms of frauds --- triggers and red-flagged cases which are suspect," says Jaiswal. 

Five companies -- Greenojo, SAS, Lexus Nexus, MFX Services and Optum -- have been shortlisted to run a six-month programme on PMJAY data as it comes in. Every red flag will be investigated. 

“The proof of concept that we are looking for from the analytics companies will give us both data on specific case and relational data as well. It will tell us if a hospital is admitting patients for emergencies in the middle of the night, if the level of emergency admissions is more than international, national or area average. It will also tell us if people from a particular village are going to a particular hospital. This is relational data which will tell us about fraud at a bigger level,” says Jaiswal.

Hospitals can conduct fraud at another level. They will hold camps and invite patients from a particular area to the hospital. Many of these patients actually do not require treatment, so it will be like a free trip to the hospital for screening. The beneficiaries will then be sent home while the hospital will go prepare fake paperwork to show operations and make a claim.  

Verifying beneficiary ID, pre-authorization for treatment, PMJAY Arogya Mitra, claim processing and finally the data analytic intelligence layer which will run both on pre-authorisation stage and claim processing stage should be able to put in enough checks to deter fraud. 

“We cannot eliminate fraud completely, but we are putting roadblocks. Fraud detection is a continuous process of upgrading to catch the perpetrators. I am gung-ho about the analytics part, which will ultimately save us. Data speaks, averages speak and aberrations speak,” says Jaiswal. 

Proof of concept is happening at the NHA level and national data will be looked at daily and for action, it will be given to State Health Authority's at state and district level action. 

“A large part of our job will be to ensure the scheme isn't misused. If it bleeds, we won't be able to expand it and really, the goal is to extend it all citizens by offering universal health coverage,” says Bhushan.

Eighteen Fraudulent websites and 59 suspect Mobile apps are already listed on the PMJAY website. They range from patient enrollment to job recruitment for the scheme.

As an Insurance veteran, Jaiswal already knows the heat map and belts of fraud. NCR, Faridabad, Noida, Meerut,  Surat and Navi Mumbai are hot spots and more have emerged. In south India, there are two-wheeler accident-related frauds. Though Jaiswal and Bhushan are clear there will be zero tolerance for patient harm, it is financial fraud, collusion and exaggeration of claims will demand special attention. They have to be nipped in the bud.

So apart from name-and-shame, whistleblower guidelines, grievance redress, for the first time, the NHA has also put in recovery, punitive action, penalties in the documents for signatory hospitals.

Ayushman Bharat Scheme: The numbers speak

Silver card letters sent out (PMJAY beneficiary identification letters from PM): 55.51 million 

Gold cards issued (PM-JAY e-cards): Over 2.49 million

Beneficiaries who availed of treatment: Over 552,000, admitted in hospitals 

Cases handled daily: Over 6,000

Hospitals that have applied (both empanelled and awaiting empanellment): 58,648 (of these 15,961 hospitals have been empaneled/in-process)

Amount already disbursed: Over 4.32 billion 

Average cost of treatment/Average claim size: Around Rs 13,000 

Largest amount dispersed so far: Rs 310,000 in the case of Automatic Implantable Cardiac Defibrillator (AICD) on November 26, at U N Mehta Institute of Cardiology Research Centre, Ahmedabad, Gujarat.