On the 12th of February, Punjab Kesari published a report about an alleged Ayushman Bharat ‘scam’. The headline said that a massive Ayushman Bharat scam of Rs 562 crores had been detected with 2.7 lakh claims being found false.
Ayushman Bharat Yojana में फर्जीवाड़े का बड़ा खुलासा, 562 करोड़ रुपये के 2.7 लाख क्लेम पाए गए फर्जी#Modigovt #AyushmanBharatYojana #Fraud #NationalAntiFraudUnit #Privatehospitals #562crorerupees #2.7lakhfakeclaimshttps://t.co/JTuwGwxNCn
— Punjab Kesari (@punjabkesari) February 12, 2025
As soon as the report was published, AAP trolls started defaming the Modi government claiming that the Ayushman Bharat scheme itself was a scam. The trolls questioned the integrity of the government claiming that the government itself was perpetrating a scam.
डंका बज रहा है दुग्गल साहब और मंडली का।
— Guramneet Singh Mangat l ਗੁਰਅਮਨੀਤ ਸ਼ਿੰਘ ਮਾਂਗਟ l (@guramneet) February 13, 2025
Fake claims in Ayushman Bharat: Rs 562.4cr fraud health insurance claims in India, 74cr of them from Punjab, Haryana, Himachal Pradesh | Chandigarh News – The Times of India https://t.co/0iuUWQTN8p
Another AAP troll questioned the media, asking why the Sheesh Mahal scam of former CM Arvind Kejriwal was being discussed instead of the Ayushman Bharat scam.
Ayushman Bharat has a probable 500 crore scam but why bother Papa ji. Let’s talk some irrelevant nonsense on prime time. https://t.co/m91egUpYMB
— Utkarsh (@Cowlogy) February 12, 2025
Yet another said that 10% of the budget allocated was a scam.
It's literally 10% fraud of the budget allocated to Ayushman Bharat yojana। https://t.co/MaOHWP9yPi
— غولرز شخ (@GulRose_views) February 12, 2025
The insinuation was that a large portion of the budget allocated for Ayushman Bharat was a scam and that it was, somehow, the government that was responsible for this scam. The insinuation also was that the government allocated Rs 562 crores for a ‘scam’, essentially, that the crores of the government money had been spent fraudulently.
However, the truth is far from it.
What is the alleged Rs 562 crores Ayushman Bharat “scam”
The news of the Ayushman Bharat Scam comes from a question which was asked in the Rajya Sabha on the 12th of February by Amarendra Dhari Singh, an RJD leader.
A part of the question asked by AD Singh was – “Whether there are instances of fake billing in Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) by private sector hospitals thereby making the poor people agree to their greed”.
The government responded to the question, talking about 2.7 lakh claims being found to be fake.
The government said, “Out of 6.66 crore claims processed by NAFU, 2.7 lakh claims of private hospitals worth Rs. 562.4 crore were found to be non-admissible on account of abuse, misuse or incorrect entries. Further, any claims by empanelled hospitals found to be suspicious by NAFU are withheld until proper scrutiny by SAFU teams including field verification where necessary”.
The response by the government makes it clear that 2.7 lakh claims worth Rs 562.4 crores were found to be ‘non-admissable’ and that, these claims were ‘withheld’ for proper scrutiny.
This would mean that the private hospitals filed their claims with the government and the ones that were found suspicious (2.7 lakh claims) were withheld for investigation and the amount was NOT disbursed to the hospitals. Essentially, there was no “scam” since no money was disbursed in fulfilment of the fraudulent claims. The response means that the private hospitals were attempting to scam the government, however, the government did not pay them for the fraudulent claims they had raised.
What are the steps taken by the government to ensure efficient detection of fraud claims, ensure zero-tolerance
The National Health Authority (NHA) has put in several measures to ensure that there is efficient detection of fraud claims by private hospitals and once those fraud claims have been detected, there are measures in place to penalise the errant hospitals.
According to the response in Rajya Sabha (PDF), the government first and foremost blacklists suspends or de-panel the errant private hospitals.
Additionally, misuse/abuse claims are rejected, and penalties or legal actions are imposed on such hospitals. To enhance the detection of misuse or abuse, near real-time monitoring and AI-based systems are used to check hospital claims. Further, hospitals undergo random audits and surprise inspections to ensure the authenticity of claims. State Health Agencies (SHAs) also conduct regular desk medical audits as well as field audits.
As a result of the stringent measures, a total of 1,114 hospitals have been de-empanelled, and 549 hospitals have been suspended under AB-PMJAY.
The National Anti-Fraud Unit (NAFU) has employed 57 different technologies to detect fraud claims before the money is disbursed. These technologies include rule-based triggers and Machine Learning algorithms, fuzzy logic, image classification and de-duplication, etc. Other technologies and interventions such as enhanced access controls to the NHA IT system, near real-time dashboards to highlight suspicious cases, regular monitoring and cleansing of databases and other data analytic techniques are also deployed.
With the response of the government, it is clear that there was no “scam” in the Ayushman Bharat scheme. There were private hospitals that attempted to defraud the government by missing the system and raising false claims. The government, on its part, used advance technologies to identify the fraud claims and put the claims on hold pending investigation. 2.7 lakh claims amounting to Rs 562 crores were detected and thwarted – resulting in no loss to the public exchequer. Further, the government has so far de-empanelled 1114 hospitals and suspended 549 hospitals as punitive measures.
