As many as 88,760 patients were recorded to have died while availing treatment under the Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), and a total of 2,14,923 claims were subsequently made towards “fresh treatment” of these same patients, reveals a performance audit report by the Comptroller and Auditor General (CAG) of India. The report, tabled in the Lok Sabha on August 7, covers the period from September 2018 to March 2021 and details numerous irregularities and incidents of data manipulation that have plagued the implementation of the Union government’s flagship health insurance scheme.
Around 7.87 crore beneficiary households are registered for the PMJAY, which aims to provide a health cover of up to Rs 5 lakh per family every year for secondary and tertiary care hospitalisation services, according to the records of the National Health Authority (NHA) that manages the scheme’s implementation on behalf of the Union government. This comprises up to 73% of the scheme’s target of 10.74 crore households. For its report, the CAG has zeroed in on a sample size of 964 hospitals from 161 districts across 28 states. Here are a few selected details from the report.
The CAG report states that after a desk audit in July 2020, the NHA was informed that the system was allowing pre-authorisation requests of even patients who were earlier recorded as ‘dead’ while availing of treatment under the scheme. The NHA acknowledged the audit comment, and said that necessary check(s) have been put in place to ensure that the PMJAY ID of dead patients would be disabled from availing further benefits, the report says.
But patients shown as dead continued to “avail treatment” even in the months that followed.
Of the 2,14,923 claims, up to 3,903 claims — pertaining to 3,446 patients and amounting to Rs 6.97 crore — were paid to hospitals. The highest number of such claims was recorded in Kerala, where 1,022 claims were made for ‘fresh treatments’ of 966 formerly dead patients. An amount of Rs 2.60 crore was paid towards these claims. This was followed by Chhattisgarh, where 404 claims were made for 365 dead patients. Haryana, Jharkhand, and Madhya Pradesh also recorded a significant number of such claims.
The Aadhaar is one of the primary ID cards to be used for registration under the AB-PMJAY. The NHA has reportedly authenticated beneficiaries with the Unique Identification Authority of India (UIDAI) through Aadhaar e-KYC (Electronic Know Your Customer) to ensure that the information furnished is authentic. In Tamil Nadu, the CAG found that multiple beneficiaries were linked with the same or erroneous Aadhaar numbers.
The NHA has stated that this has happened because Tamil Nadu is using its own IT platform and database for beneficiary identification. It urged the state to migrate to the Aadhaar-based BIS platform of NHA to strengthen the verification protocol. At the same time, the report notes that the successful generation of multiple e-cards (PMJAY ID) against the same/erroneous Aadhaar number indicates a “lack of essential validation controls.”
Though communications related to the scheme such as post-discharge feedback is expected to be done through the contact number provided by the beneficiary, the CAG reveals that there are large numbers of beneficiaries registered against the same or invalid mobile number. For instance, the BIS database links as many as 7.49 lakh beneficiaries to a single invalid phone number ‘9999999999’. There are 1.39 lakh people whose registered phone number is mentioned as ‘8888888888’. Another 96,046 beneficiaries have their number as ‘9000000000’.
Once a beneficiary is verified to be eligible, a PMJAY ID — a nine-digit alphanumeric code that is supposed to serve as a unique identification key — is supposed to be assigned to them. But CAG’s data analysis found that this ID was not unique in as many as 1.57 lakh approved cases.
“The presence of duplicate IDs in the system indicates failure of the system to generate a unique ID for each beneficiary. In such circumstances, the possibility of the presence of ineligible beneficiaries in the BIS database cannot be ruled out,” the CAG report says.
The audit also revealed that in up to 43,197 households, the size of the family was unrealistic, ranging from 11 to 201 members. It is to be noted that there is no cap on family size for eligible households in the guidelines. The report says that the presence of such unrealistic members in a household in the BIS database points towards the lack of essential validation controls in the registration process.
Besides, the NHA has used the Socio-Economic and Caste Census (SECC) database of 2011, seven years old at the time of PMJAY’s inception, as the eligibility criteria for the scheme. Even if we do not factor in the economic development and employment opportunities that could have realistically changed the dynamics of the said census data, the SECC database has also been found to be riddled with several inconsistencies, including invalid and blank entries on name and gender columns, unrealistic dates of birth such as ‘1814’ and ‘1824’, etc.
As per the scheme’s beneficiary identification system (BIS) guidelines, relevant documents are to be approved for insurance claims only after the details of the applicant are matched with the list of eligible beneficiaries. For this, a ‘match confidence score’ of one to 100 is generated online based on the level of documents matched. In the absence of any uniform threshold for this score by the NHA, approvals and rejections were made irrespective of the confidence score, the report says.
The CAG’s data analysis revealed that the match confidence score was not applied as a criterion during the approval/rejection process of registration of a person. Up to 32.25% of the 11.38 crore approved cases failed to even generate a match confidence score, while the score was zero for around 14.84% of the cases. On the other hand, nearly 40.65% of the 94 lakh rejected applications had a match confidence score of 51 to 100.
As of November 2022, a total of 26,209 — 11,930 private and 14,279 government — hospitals were empanelled across India’s states and union territories. According to the PMJAY scheme’s hospital empanelment and management (HEM) guidelines, the Empanelled Health Care Providers (EHCPs) should meet certain minimum requirements.
These criteria were not met by some of the EHCPs in 12 states/UTs, namely Andaman and Nicobar Islands, Assam, Bihar, Chandigarh, Gujarat, Himachal Pradesh, Jammu and Kashmir, Manipur, Nagaland, Puducherry, Tripura, and Uttar Pradesh, the CAG report says. The centres reportedly had “deficiencies such as medical equipment being out of order, lack of basic infrastructure such as IPD beds, operation theatres, ICU care with ventilator support systems, pharmacy, dialysis unit, blood banks, round-the-clock ambulance services.”
The report also says that in Bihar, Himachal Pradesh, Jharkhand, Karnataka, Meghalaya, Puducherry and Uttarakhand, some of the hospitals were empanelled even though they did not comply with appropriate fire safety measures, standard treatment guidelines, and waste management support services. The State Health Agencies (SHAs) are required to ensure that the EHCPs follow all the norms and safety measures.
The availability of EHCPs was very low in the states/UTs of Assam (3.4 per lakh beneficiaries), Dadra Nagar Haveli-Daman Diu (3.6), Maharashtra (3), and Rajasthan (3.8). Though beneficiaries in Bihar and Uttar Pradesh are numerous at 5.56 crore and 6.47 crore, availability of EHCPs was very low in comparison at 1.8 and five EHCPs to a lakh of the population respectively, the report says.
The CAG audit also notes instances of either zero or low performance in several states, especially Andhra Pradesh, Jharkhand, Punjab, Tamil Nadu, and Uttar Pradesh. In Andhra, for instance, out of 1,421 empanelled EHCPs, 524 submitted zero claims while 81 submitted one to five claims — indicating that they are not fully functional. In Jharkhand, it was found that 59 EHCPs were not treating patients since empanelment. In Punjab, five selected EHCPs in five test-checked districts did not provide any treatment up to March 2021. None of the 19 EHCPs empanelled in September 2020 in Tamil Nadu were entertaining patients under the scheme as of March 31 2021. Out of the 416 EHCPs in seven districts in Uttar Pradesh, 40 did not provide any treatment.
Beyond these, the CAG report also details issues such as inordinate delays in authorisation and settling of claims, excessive and inadmissible payments made to EHCPs, faulty formats of data maintenance, transfer of grants to states/UTs before the implementation of the scheme, SHAs’ failure to remit interest on unspent grants, and several more such discrepancies and irregularities.