KASP issues: CAG report puts State Health Agency in the dock

Kerala's Ayushman Bharat-Karunya Arogya Suraksha Padhati (KASP) health insurance scheme has been a major fiscal disaster, with cost overruns and overdue claims. CAG audit report reveals how the State Health Agency (SHA) has been running the scheme with no checks and balances, resulting in frauds and unauthorised payments. SHA failed to conduct necessary audits, leading to financial ruin of public hospitals and Rs. 1,400-1,630 crore claims settlement in 2021-22 and 2022-23 respectively.

Kerala’s health insurance scheme, Ayushman Bharat-Karunya Arogya Suraksha Padhati (KASP), has undoubtedly been a major fiscal disaster, with huge cost overruns and high rate of overdue claims.

To those wondering how an insurance scheme meant to provide health cover for the poor can end up as the State’s nemesis, the Comptroller and Auditor General’s (CAG) just-released audit report on AB-PMJAY would be an eye-opener.

The report is a telling commentary on how the implementing agency of KASP – the State Health Agency (SHA) – has been running the scheme with no checks and balances, that Kerala now figures prominently in all the major lapses/frauds that the CAG has unearthed .

According to the CAG report, as on November 22, the total unprocessed claim amount across the country is ₹6,052.43 crore, of which Kerala accounts for unsettled claims worth ₹985.28 crore, from 8,43,790 claims.

The CAG report clearly states that “Kerala’s SHA had not conducted any medical audit, death audit, beneficiary audit (post discharge through home visit), pre-authorisation audit, and claim audits (rejected as well as approved claims).

More seriously, the Third Party Administrator (TPA) contracted by Kerala’s SHA to scrutinise claims had also not conducted any beneficiary audit (post discharge through telephone and home visits) or preauthorisation of claims audit”

“The shortfall in conduct of audits resulted in a lax control environment with possibility of unauthorised/ excess payments of claims, fraud and shortcomings in facilities to be provided to the beneficiaries,” the CAG has noted.