Examining recommendations of CAG audit report on AB PM-JAY: Health ministry

Union Health Ministry on Thursday said the recommendations made by the Comptroller and Auditor General (CAG) in its performance audit report on the Ayushman Bharat- Pradhan Mantri Jan ArogyaYojana (AB-PMJAY) were being examined.

CAG tabled a performance audit report in the Lok Sabha on August 7 on the operationalisation of the AB-PMJAY scheme in hospitals.

Refuting media reports claiming that the CAG has flagged treatments booked for AB PM-JAY beneficiaries, who have been declared dead on the system, the Health Ministry said the reports are misleading.

"It is clarified that under AB PM-JAY, hospitals are allowed to initiate a request for pre-authorization three days in advance, prior to the date of admission in the hospital. This feature is enabled to avoid denial of treatment in case of limited connectivity, emergency situations," the ministry said in a statement.

"In some cases, the patients got admitted and before their pre-authorization was raised, they died during the treatment. In such cases, the date of death is the same as the admission date or earlier. Moreover, death has also been reported by the same hospital which raised the pre-authorization request. Thus, had the hospital intended to defraud the system, it would not have shown any interest in declaring the patient dead on the IT system," it added.

Health Ministry said more than 50 per cent of cases highlighted in the report have been booked by public hospitals that have no incentive in committing fraud, as the money is reimbursed in the hospital account.

"Further, in case of death during treatment, the hospital has to mandatorily submit a mortality report," the ministry said.

"Regarding the same patient availing treatment in two hospitals at the same time, it may be noted that under AB PM-JAY, children up to 5 years of age avail treatment on the Ayushman Card of their parents. Accordingly, Ayushman Card can simultaneously be used for children and parents in two different hospitals," it added.

The ministry stated further that a four-step robust claim processing system has been deployed under AB PM-JAY.

"At every step, the veracity of the hospital's claims is examined. Further, defined triggers are run on claims to identify cases that need further examination," the ministry added in its statement.

Further, according to the ministry, there are no operational or financial implications for a beneficiary after a mobile number was found associated with multiple beneficiaries in the CAG report.

The ministry added that the beneficiary identification process under Ayushman Bharat PM-JAY is not linked with the mobile number.

"The mobile number is captured only for the sake of reaching out to the beneficiaries in case of any need and for collecting feedback regarding the treatment provided. Ayushman Bharat PM-JAY identifies beneficiaries through Aadhaar identification wherein the beneficiary undergoes the process of mandatory Aadhaar-based e-KYC," it said.

"The details fetched from the Aadhar database are matched with the source database and accordingly, the request for Ayushman card is approved or rejected based on the beneficiary details. Thus, there is no role for mobile numbers in the verification process," it added.

Further, AB PM-JAY caters to a beneficiary base (bottom 40 per cent) wherein many of them may not possess mobile phones or the numbers keep changing at frequent intervals, the ministry noted.

It added that the treatment to the beneficiaries can't be withheld just on the grounds that he/she doesn't carry a valid mobile number, or the mobile number given by them has changed.

"Accordingly, beneficiary mobile numbers have a very limited role in the AB PM-JAY treatment workflow," the ministry stated, adding, "Thus, mobile numbers have no role in deciding beneficiary eligibility. Therefore, it is an erroneous presumption that beneficiaries can avail treatment using the mobile number".

The National Health Authority and the Ministry of Health and Family Welfare are examining in detail the recommendations of the CAG's performance audit report and necessary action is being taken to make the system more robust, efficient and prudent by strengthening the existing IT platform and processes, the ministry added in its statement.