Lapses in Ayushman Bharat Scheme: Parliamentary Committee Reports Ineligible Beneficiaries and Excess Premium Payments

A parliamentary committee report has revealed that ineligible beneficiaries received benefits from the Ayushman Bharat health insurance scheme due to insufficient validation checks. The audit also found records of deceased patients continuing to receive treatment. Recommendations include enhanced validation mechanisms, timely registration, and strict adherence to guidelines.

Ineligible beneficiaries received benefits under the Ayushman Bharat health insurance scheme, leading to excess premium payments to insurance companies, a parliamentary committee has revealed. The committee emphasized the need for in-built validation checks to avoid invalid entries.

According to the report, patients previously recorded as deceased in the Transaction Management System (TMS) continued to receive treatment under the scheme.

The Performance Audit of the Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) by the Public Accounts Committee was tabled in Parliament this week. It highlighted that 88,760 patients were recorded as having died during treatment, yet 2,14,923 claims appeared for fresh treatment of these patients.

The audit found that the TMS allowed preauthorization requests for beneficiaries noted as dead, as well as other entries like admission, surgery, and discharge dates. The Union Health Ministry has assured that the updated TMS version will have all necessary validations in place.

The committee's report also stressed the need for a more thorough audit to check the accuracy of claims for deceased patients. Additionally, delays in registration requests were found to deny benefits to potential beneficiaries.

It was recommended that the states provide an Aadhaar-seeded database of all beneficiaries to ensure proper de-duplication and that any ineligible individuals be promptly removed from the list of eligible beneficiaries.

The panel noted inadequacies in the process of identifying and verifying beneficiaries and cited that only 73 percent of the target households had been registered as of November 2022.

The committee also addressed the failure of insurance companies to meet the claim ratios, resulting in significant refunds due. Out of the Rs 700.10 crore recoverable, only Rs 241.91 crore has been partially recovered.

Recommendations include streamlining the refund mechanism, enforcing physical verification for hospital empanelment, and ensuring strict adherence to the PMJAY guidelines across all states.