AB-PMJAY employs AI anti-fraud initiative, collects ₹9.5 crore in penalty

A penalty amount of ₹9.5 crore has been recovered while 5.3 lakh Ayushman cards have been disabled and 210 hospitals de-empanelled based on information of fraud in the AB-PMJAY

A penalty amount of ₹9.5 crore has been recovered while 5.3 lakh Ayushman cards have been disabled and 210 hospitals de-empanelled based on information of fraud obtained through artificial intelligence and machine learning-based anti-fraud initiative protecting the world’s largest government-run insurance scheme Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), according to data with the Health Ministry viewed by The Hindu.

Around 0.18% of the total authorized hospital admissions under the scheme have also been confirmed as fraud since its inception. Additionally, 188 hospitals have been suspended and penalty of ₹20.17 crore levied across board as part of the anti-fraud drive.

“Besides routine checks the use of AI is now made for a comprehensive fraud analytics solution to detect fraud pro-actively, develop algorithms that can be used on large volume of data to identify suspect transactions and entities and risk scoring of hospitals and claims,” the Ministry noted.

Previously the National Health Authority (NHA) — the implementing agency of AB-PMJAY — issued a comprehensive set of anti-fraud guidelines. 

“Anti-fraud advisories were also issued to States/UTs. National Anti-Fraud Unit (NAFU) was created at NHA for overall monitoring and implementation of anti-fraud framework supported by State Anti-Fraud Units (SAFUs) at State level,” said a senior Health Ministry official.

He added that the scheme is governed by zero-tolerance approach to any kind of fraud viz. suspect/non-genuine medical treatment claims, impersonation, and up-coding of treatment packages/procedures etc.

“All claims require mandatory supporting documents along-with on-bed patient photo before approval and payment,” noted the Ministry.