New Delhi: Actions including de-empanelment of 1,114 hospitals, levying penalty worth Rs 122 crore on 1,504 errant hospitals and suspension of 549 hospitals have been taken against fraudulent entities under the Ayushman Bharat Health Insurance scheme as reported by the states and Union Territories (UTs), the Lok Sabha was told on Friday.
In a written reply, Minister of State for Health and Family Welfare Prataprao Jadhav said that Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is governed on a zero-tolerance policy towards misuse and abuse. Various steps are taken for prevention, detection and deterrence of different kinds of irregularities that could occur in the scheme at different stages of its implementation, he added.
A robust anti-fraud mechanism has been put in place and the National Anti-Fraud Unit (NAFU) has been set up with the primary responsibility for prevention, detection and deterrence of misuse and abuse under AB-PMJAY.
“Suitable actions including de-empanelment of 1,114 hospitals, levying penalty worth Rs 122 crore on 1,504 errant hospitals and suspension of 549 hospitals have been taken against fraudulent entities as reported by the states and UTs,” Jadhav said.
According to the terms and conditions of empanelment, hospitals cannot deny treatment to eligible beneficiaries of the scheme. In case of denial of treatment by the empanelled hospital, beneficiaries can lodge complaints, he said.
Under the AB-PMJAY, a three-tier grievance redressal system at the district, state and national level has been created to resolve the issues faced by beneficiaries in utilising healthcare services.
There is a dedicated nodal officer and grievance redressal committees at each level to address the grievances. Beneficiaries can file their grievances using different mediums including web-based portal, centralised grievance redressal management system (CGRMS), central and state call centres (14555), email, letter to state health agencies (SHAs) and the like. Based on the nature of the grievance, necessary action including providing support to the beneficiaries in availing treatment under the scheme is taken, Jadhav said.
Settlement of claims is an ongoing process. Under the AB-PMJAY, claims are settled by respective SHAs. The NHA has laid down guidelines for the payment of claims to hospitals within 15 days of claims submission for the intra-state hospitals (hospitals located within a state) and within 30 days in case of portability claims (hospitals located outside a state), the minister informed.
Claims are required to be settled within the timeline specified under the scheme. Notable improvements have been recorded in the overall average turnaround time (TAT) for claim settlements year on year.
Regular review meetings are organised to take stock of the progress with regard to the claims. Further, capacity-building activities are organised for efficient claims settlement, he said.
