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
- Beneficiary fraud
- Payer (trust or insurance company) fraud and
- Provider (hospital) fraud
- Methodology
- Fraud prevention
- QR code-based beneficiary identification
- Provider empanelment: Over 8,000 hospitals will join the network of empanelled facilities
- Pre-authorization for hospitalization.
- 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
- 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:
- Insurance Mode
- Trust Mode
- 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.
