National health scheme: Focus on system to check fraud

The News

  • The Health Minister released the Anti- Fraud Guidelines to check fraud related to the Pradhan Mantri Jan Arogya Yojana.

 

Context

  • The government has announced the nation-wide roll out of the National Health Protection Mission-Ayushman Bharat, rechristened as Pradhan Mantri Jan Arogya Yojana on 25th of September.

 

Anti-fraud Guidelines

National Health Agency under Ministry of Health has prepared the comprehensive anti-fraud guidelines.

  • Definition of Fraud

Situations that constitute fraud include impersonation, counterfeiting, misappropriation, criminal breach of trust, cheating, forgery, falsification and concealment.

  • Categorisation of Fraud
  1. Beneficiary fraud
  2. Payer (trust or insurance company) fraud and
  3. Provider (hospital) fraud
  • Methodology
  1. Fraud prevention
  • QR code-based beneficiary identification
  • Provider empanelment: Over 8,000 hospitals will join the network of empanelled facilities
  • Pre-authorization for hospitalization.
  1. Fraud Detection
  • Data Analytics: Data analytics companies to provide a ‘proof of concept’ design for a effective prevention and detection system. Integration of AI and machine learning algorithms for state-of-art fraud detection platform involving the data analytics companies.
  • Social Monitoring
  • Audits including public and social audits: 100 per cent death audits
  1. Deterrence
  • Contract Management
  • Anti-Fraud Cells at state and national level.
  • Penalties: Monetary, de-empanelment or under IPC section.

 

About Pradhan Mantri Jan Arogya Yojana

  • Health Insurance cover of Rs. 5 lakh per family per year.
  • Targets over 10 crore families belonging to poor and vulnerable population based on Socio Economic and Caste Census 2011 (SECC)
  • No cap on family size and age.
  • All 29 states and UTs have signed MoUs with the Centre towards the implementation of the scheme.
  • States to decide among 3 modes of implementation:
  1. Insurance Mode
  2. Trust Mode
  3. Mixed Mode
  • Benefits will be portable across the country.
  • No enrollment is required for beneficiaries.
  • The scheme is completely cashless meaning the beneficiary will not make any payment to obtain services at empanelled hospitals.

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