Dead patients getting treatment under PM-JAY? Health Ministry replies

Media reports claiming that Ayushman Bharat PM-JAY beneficiaries who are already dead are still on the system getting treatment are misleading, the health ministry said on Thursday.

The ministry also said that mobile numbers have no role in deciding beneficiary eligibility.

The ministry's remarks came in response to media reports that claimed 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.

The reports also claim that the same beneficiary had been found to avail treatment at two hospitals at the same time. "These media reports are completely misleading and ill-informed," the ministry said.

The CAG report which contains results of the Performance Audit on Ayushman Bharat Pradhan Mantri - Jan Arogya Yojana (AB PM-JAY) covering the period September 2018-March 2021 was placed in parliament in the Monsoon Session of 2023, the ministry said in a statement.

"It is clarified that under AB PM-JAY, hospitals are allowed to initiate requests for pre-authorization up to three days post the date of admission in the hospital. This feature is enabled to avoid denial of treatment in case of limited connectivity, emergency situations, etc," the statement said.

In some cases, the patients were admitted and before their pre-authorisation was raised, they died.

"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 the IT system," the statement said.

It is pertinent to note that more than 50 per cent of cases highlighted in the report have been booked by public hospitals, which have no incentive in committing fraud, as the money is reimbursed in the hospital account, it said.

Further, in case of death during treatment, the hospital has to mandatorily submit a mortality report, it said.

There are also many instances where the patients were admitted in the hospital as private patients (self-paid) but when they discovered the scheme, they requested the hospital to register them under the scheme for free treatment, the statement said.

The feature that allows back-dated pre-authorisation helps save people out-of-pocket expenditure.

On the patient getting treatment in two hospitals at the same time, the statement said that under AB PM-JAY, children up to 5 years of age avail treatment on the Ayushman Card of their parents.

Accordingly, Ayushman Cards can simultaneously be used for children and either of parents at two different hospitals, it said.

Usually, mother and child avail treatment using one Ayushman Card only, and if the child dies during treatment, the hospital declares the child dead which erroneously gets registered against the card of the mother, the statement said.

Subsequently, when the mother comes for next treatment, she is denied services on the grounds of her Ayushman Card being marked as 'dead.' In such cases, grievances are raised, and the 'dead flag' against the card of mother is removed, it said.

The government said it has deployed a four-step robust claim processing system under AB PM-JAY with the veracity of the hospital's claims examined at each step, the statement said.

It said defined triggers are run on claims to identify cases which need further examination. Such cases undergo desk and field audits and in case a hospital is found to be committing any fraud or abuse, penal actions including de-empanelment are initiated against the erring hospital.

The CAG finding one mobile number associated with multiple beneficiaries has no operational and financial implications as beneficiary identification process under Ayushman Bharat PM-JAY is not linked with the mobile number, the ministry said.

"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," the statement said.

Ayushman Bharat PM-JAY identifies beneficiaries through Aadhaar identification.

"The details fetched from the Aadhaar database are matched with the source database and accordingly, the request for Ayushman card is approved or rejected based on the beneficiary details. Thus, there is no role of mobile numbers in the verification process," the statement said.

The AB PM-JAY caters to a beneficiary base (bottom 40 per cent) where many of them may not possess a mobile number or keep changing it frequently, it said.

Accordingly, the NHA has provided three additional options, i.e. fingerprint, iris scan, and face-authorisation for beneficiary verification along with OTP, of which fingerprint-based authentication is most used.

In view of the above, treatment to the beneficiaries can't be withheld just on the grounds that the beneficiary doesn't carry a valid mobile number, or the mobile number given by them has changed, the statement said.

"Accordingly, beneficiary mobile numbers have a very limited role in the AB PM-JAY treatment workflow. Also, the fact that PM-JAY is an entitlement-based scheme and not an enrolment-based scheme and therefore, the beneficiary database is fixed and cannot be edited to add new beneficiaries.

"Thus, mobile numbers have no role in deciding beneficiary eligibility. Therefore, it is an erroneous presumption that beneficiaries can avail treatment using mobile number," the statement stated.

The ministry also argued that since there was a field that asked for 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.

The OTP-based validation was not on initially as many beneficiaries either didn't carry the mobile with them or they shared the number of their relative or neighbour.

The ministry in the statement said that the National Health Authority and Ministry of Health and Family Welfare are examining in detail the recommendations of CAG performance audit report and necessary action is being taken to make the system more "robust, efficient and prudent."