The first ever CAG report on the PMJAY highlights how the scheme has been riddled with corruption and visible fraudulence.
New Delhi: The Comptroller and Auditor General (CAG) report on the assessment of Pradhan Mantri Jan Arogya Yojana (PMJAY) – one of the two components of Ayushman Bharat scheme – has shown that despite being a highly important intervention of the Narendra Modi government to address health needs, it remains riddled with corruption of various kinds.
The funding of the scheme is shared between the state governments and the Union in the ratio of 60:40. At the Union government-level, the National Health Authority (NHA) is responsible for scheme implementation. In states, the job has to be done through state health authorities (SHAs) and district implementations units. The scheme aims to provide Rs 5 lakh per family as per the strict criteria defined in the scheme.
As per the NHA database, 24.42 crore beneficiaries have been registered for the scheme till date and Rs 67,456.21 crore has been spent on their hospital admissions.
The CAG assessment included the time period of September 2018 to March 2021 – part of which coincides with the COVID-19 pandemic. The auditor test checked 964 hospitals in 161 districts of all 28 states and Union territories (UTs). Delhi, Odisha and West Bengal have opted out of this scheme.
It is the first CAG report on the PMJAY.
The auditors found large scale corruption in insurance claims settlement. It reported that not enough validation was done by the SHAs before releasing the claims to the hospitals which were empanelled under the scheme. It noted that in 2.25 lakh cases, the date of the ‘surgery’ done was shown to be later than the date of discharge. Of all such cases, more than 1.79 lakh were found in Maharashtra for which the claimed amount was over Rs 300 crore.
In other instances, the hospitals had made claims and the SHAs had transferred money for dates even before the inception of the scheme. The payments were made to hospitals in some cases prior to submission of claims. In other cases, patients above 18 years of age were given treatment under ‘paediatric speciality packages’.
The audit also found that in 45,846 claims, the date of discharge was earlier than date of admission. Furthermore, the audit found several cases where one patient had been shown to be hospitalised in multiple hospitals at one given point in time.
Lakhs of claims continued to be made against some who had been shown as ‘deceased’ in the database.
The data in the Transaction Management System (TMS) showed that 88,760 patients had died during treatment. And yet, 2,14,923 claims were shown as paid in respect of ‘fresh treatments’ given to these dead ‘patients’. Almost Rs 7 crore was spent towards settling these claims in 24 states and UTs. The maximum number of such cases were observed in Chhattisgarh, Haryana, Jharkhand, Kerala and Madhya Pradesh.
Lakhs of cards issued to beneficiaries were cancelled just as they were registered owing to malpractices. But the TMS – the system in place – failed to ensure that the pre-authorisation request for claims by hospitals made against these cards be restricted. As such, Rs 71.47 lakh were paid towards beneficiaries registered as per these ‘disabled’ cards.
As far as caution against bogus 11.04 lakh beneficiaries is concerned, the NHA generated many alerts to the SHAs. The SHAs could investigate only 7.07 lakh cards. The highest number of such fraud claims were made in Gujarat, Madhya Pradesh, Meghalaya and Uttar Pradesh.
One unique; id several beificial
One of the biggest instances of graft in the implementation of this scheme was found in registration and identification of beneficiaries.
The scheme stipulates that a unique PMJAY ID should be issued to beneficiaries once verification is complete. The audit discovered that 1.57 unique IDs appeared more than once in the database. In other words, all these IDs were duplicated. “In such circumstances, possibility of presence of ineligible beneficiaries in the Beneficiary Identification System [BIS] database cannot be ruled out,” the report said.
Besides Aadhaar numbers, the system also utilises the phone numbers of beneficiaries. The audit brought to light that there were large numbers of beneficiaries registered against the same or invalid mobile number. For example, 7.5 lakh beneficiaries were registered against the ‘9999999999’ mobile number and another 1.4 lakh under the ‘8888888888’ number.
After the CAG report was released, an anonymous source of Union health and family welfare ministry has been quoted by PTI as saying that the scheme only used mobile numbers to reach out to the beneficiaries in case of any need and for collecting feedback regarding treatment, rather than for verification purposes.
The unnamed official went on to add: “AB-PMJAY identifies the beneficiary through Aadhaar identification wherein the beneficiary undergoes the process of mandatory Aadhaar based e-KYC. The details fetched from the Aadhaar database are matched with the source database and accordingly, the request for Ayushman card is approved or rejected based on the beneficiary details.”
What about Aadhaar?
But according to the audit report not all is well with Aadhaar identification either. Two registrations each were found to be made against 18 Aadhaar cards. On the other hand, in Tamil Nadu, 4,761 registrations were made against seven Aadhaar numbers, the audit found.
What is further surprising is the fact that as per the scheme guidelines, the SHAs have to send SMS notifications to the contact number provided to check their eligibility. So in the backdrop of such large-scale duplication of numbers, it is unclear as to whether those SMS notifications were indeed sent, and if they were sent, who received them.
“Mobile numbers are significant for searching records related to any beneficiary in the database, who may approach the registration desk without the ID,” the auditors say.
“In case of loss of e-card, identification of the beneficiary may also become difficult. This may result in denial of scheme benefits to eligible beneficiaries as well as denial of pre- and post-admission communication causing inconvenience to them,” they go on to add.
While in its statement the ministry tried to downplay the duplication of mobile numbers, the audit report says the NHA had “agreed with audit observation” and assured that the deployment of BIS 2.0 would arrest this practice. And as such, the data entry operators would not be able to enter “random numbers” during the registration process.