AI-based watch, SOP for hospitals: Gujarat takes steps to check PMJAY fraud

A month after unnecessary angioplasty caused the deaths of two Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) beneficiaries at an Ahmedabad hospital, the Gujarat government has imposed a blanket ban on all free medical camps and taken a series of measures to prevent such scams. The surgeries were allegedly done only to bag the PMJAY funds.

The State Health Agency (SHA), a nodal agency responsible for implementing the PMJAY scheme in the state and which comes under the National Health Authority (NHA), has also decided to digitize the process in Gujarat. Taking a leaf out of the Delhi Health Department’s book, the SHA will reportedly develop a portal enabled by artificial intelligence (AI) to flag fake, incomplete, or non-compliant documents immediately.

The state government will also introduce a new Standard Operating Procedure (SOP) in private hospitals with PMJAY facilities. All these were discussed in a meeting held in Gandhinagar last week by Health Minister Rushikesh Patel, Principal Secretary Dhananjay Dwivedi, Health Commissioner Harshad Patel, and PMJAY-MA CEO Remya Mohan with doctors from various government and private hospitals.

Also read: Gujarat PMJAY fraud | Paediatrician falsely 'treats' 116 healthy infants

Focus on four departments

The health minister said the government will focus on four departments — cardiac issues, oncology, paediatrics, and ortho-surgery. He said these four are the most misused categories, as these allow the maximum amount of insurance under the PMJAY-MA scheme, a hybrid of the Centre’s Ayushman Bharat and the Gujarat government’s Maa Amrutam Yojna.

“While the Union government gives up to Rs 5 lakh for cases in these specialities, the Gujarat government assures an additional amount up to Rs 10 lakh under the Maa Amrutam Yojna,” he said. “We have identified the loopholes in the current system, which will be replaced with a strict SOP to ensure that provisions of PMJAY are not misused,” Patel said.

According to the SHA data, the largest number of surgeries under PMJAY have been done for knee replacement (ortho-surgery) followed by cardiac procedures. These two specialties also account for the maximum amount of PMJAY fraud.

Also read: Gujarat doctor arrested for death of PMJAY beneficiaries in ‘botched’ angioplasty

SOP for hospitals

According to the new SOP that will be formally announced this week, a two-tier check will be implemented. After a doctor suggests surgery, a team of doctors appointed by the SHA will review and give the final approval.

For oncology (cancer) treatments under the scheme, Tumor Board Certificates (TBCs) will also be made mandatory. An online portal will be developed by the SHA for that.

The new SOP would also mandate the scheme-empaneled hospitals to be registered under the Clinical Establishment Act. Several teams of the State Anti-Fraud Units (SAFU) will be set up at the district and state levels which would conduct surprise visits throughout the year.

Also read: How private hospitals in Gujarat are fiddling with lives to mint PMJAY benefits

How PMJAY currently operates

Currently, the SHA in Gujarat is headed by a CEO appointed by the state government. The CEO is also the ex-officio member secretary of the Governing Council of the SHA, which in turn, is headed by the Chief Secretary of the state.

The SHA oversees the implementation of PMJAY in the state and is also responsible for data sharing, verification, and validation of family members, awareness drives, monitoring the everyday operations of the scheme, and detection of fraud.

There are District Implementation Units (DIUs) under the SHAs to support the implementation of the scheme at the local level, which are headed by the District Collectors with the primary functionary being the Chief District Health Officer (CDHO) who also coordinates with Bajaj Finance — the insuring agency that has a tie-up with the government and other implementation agencies.

The SHA had been maintaining the whole process manually to monitor the 36 crore-plus Ayushman cards created so far, leading to 6.86 crore hospital admissions till December. Of the total admissions under the scheme, 17,094 were in public hospitals and 13,806 in private hospitals.

Also read: ‘Politics’ over PM-JAY: Stats show non-BJP states used scheme better

Action against hospitals

The multi-crore scam came to light after two patients of the Ahmedabad-based Khyati Multi Specialty hospital died on November 11 after undergoing unnecessary angioplasty. Later, another paediatric hospital was flagged for admitting 116 neo-natal patients and subjecting them to unnecessary “treatment” to bag PMJAY funds.

The incidents prompted the Gujarat government to crack down on irregularities in the Ayushman Bharat scheme across the state. The Gujarat Medical Council (GMC) has also cancelled the license of 12 doctors in connection with the scam.

On December 18, four hospitals — Krishna Surgical Hospital and Swastik Multispeciality Hospital in Rajkot, Jayaben Modi Hospital in Bharuch, and Bankers Super Specialty Hospital in Vadodara — were banned from the PMJAY scheme. With these, the number of hospitals to face action by the SAFU for misusing the PMJAY scheme has risen to 16 since last month.

Apart from SAFU, the hospitals are also being probed by the CID (Crime Branch), Ahmedabad.