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Mahesh

03/08/22 06:33 AM IST

Anti-fraud system for India’s National Health Insurance Scheme

In News 
  • National Anti-Fraud Unit (NAFU) is created at NHA for overall monitoring and implementation of anti-fraud framework supported by State Anti-Fraud Units (SAFUs) at State level.
AB-PMJAY
  • Ayushman Bharat –Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is governed on a zero-tolerance approach to any kind of fraud viz. suspect/non-genuine medical treatment claims, impersonation and up-coding of treatment packages/procedures etc.
  • The Government of India adopts a pro-active approach towards fraud and abuse.
  • It goes on to underscore that several countervailing strategies have been employed under PM-JAY to address various types of fraud and it acknowledges the success of the AI-based technologies deployed under the scheme.
  • National Health Authority -the implementing agency of AB-PMJAY has issued a comprehensive set of anti-fraud guidelines.
  • The feature of Aadhar-based biometric verification of beneficiary at the time of admission and discharge is launched at all private hospitals.
  • Use of artificial intelligence and machine learning is 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.
  • Around 0.18% of the total authorized hospital admissions under the scheme are confirmed as fraud since its inception.
Features of AB-PMJAY 
  • It offers a sum insured of Rs.5 lakh per family for secondary care (which doesn’t involve a super specialist) as well as tertiary care (which involves a super specialist).
  • Under PMJAY, cashless and paperless access to services are provided to the beneficiaries at the point of service.
  • Health Benefit Packages covers surgery, medical and day care treatments, cost of medicines and diagnostics.
  • Packaged rates (Rates that include everything so that each product or service is not charged for separately).
  • They are flexible, but they can’t charge the beneficiary once fixed by the hospitals.
  • The scheme also has prescribed a daily limit for medical management.
Source- PIB 

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