The government on Thursday flagged the media reports that claimed that there were irregularities in the audit of the Ayushman Bharat-PMJAY health insurance scheme to be completely false and misleading.
In a performance audit, under the head "Treatment of a beneficiary shown as 'died' during earlier claim/treatment", the CAG had noted that “patients earlier shown as ‘died’ in TMS (the Transaction Management System of the scheme) continued to avail treatment under the scheme".
The audit noted that there were 3,903 such claims, pertaining to 3,446 patients and that Rs 6.97 crore was paid to hospitals across the country.
"There have been media reports claiming that the Comptroller and Auditor General of India (CAG) has flagged that treatments have been booked for AB PM-JAY beneficiaries who have been declared dead on the system. It further claims that the same beneficiary had been found to avail of treatment across two hospitals at the same time. These media reports are completely misleading and ill-informed," said the government.
It clarified that under Ayushman Bharat, hospitals are allowed to initiate requests 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, etc.
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 record.
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.
For example, a mother may be admitted to a hospital and delivers a baby during treatment and the hospital where the mother is availing treatment may not have a neo-natal care facility available, therefore, the child may be shifted to some other hospital with a neo-natal care facility available. In this case, the mother’s Ayushman Card is simultaneously being used for both, the baby and the mother.
Another example can be of a father and baby being treated simultaneously in two different hospitals on the Ayushman Card of the father.
The government also dismissed reports that claimed the CAG found that one mobile number was associated with multiple beneficiaries.
"It has no operational and financial implications as 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," it clarified.
"With regard to the use of the same mobile number by multiple beneficiaries, it may be noted that the mobile number is not a mandatory field for beneficiary verification. However, since there was a field for collecting mobile numbers, it is possible that some random ten-digit number was entered by the field-level workers in some cases in the earlier stages of the scheme implementation.
Initially, OTP-based validation was not enabled as many beneficiaries either didn’t carry the mobile with them or shared the number of their relative or neighbour. However, non-validation of mobile numbers wouldn’t impact either the correctness of the beneficiary verification process or the validity of the beneficiaries’ eligibility under the scheme," it added.
Necessary changes have subsequently been made in the current IT portal used by NHA for capturing only valid mobile numbers, in case the same is possessed by the beneficiary.
The report of the Comptroller and Auditor General of India which contains results of the Performance Audit on Ayushman Bharat Pradhan Mantri - Jan Arogya Yojana (AB PM-JAY) covering the period September 2018 to March 2021 was placed in parliament in the Monsoon Session of 2023, said the government.