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A recent report by a parliamentary committee has uncovered significant lapses in the Ayushman Bharat health insurance scheme, revealing that ineligible beneficiaries have received benefits due to insufficient validation checks. The report also highlights cases of deceased patients continuing to receive treatment, leading to unnecessary financial strain on the program.
The Performance Audit of the Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), conducted by the Public Accounts Committee, was tabled in Parliament this week. The audit exposed critical flaws in the Transaction Management System (TMS) used to administer the scheme. According to the findings, 88,760 patients were recorded as deceased during their treatment period, yet an alarming 2,14,923 claims were made for their treatment after their deaths.
The committee’s report reveals that the TMS allowed preauthorization requests for patients noted as deceased, and the system failed to accurately manage updates for admission, surgery, and discharge dates. The Union Health Ministry has pledged to address these issues by implementing necessary validations in an updated TMS version.
The committee has called for a thorough audit to ensure the accuracy of claims related to deceased patients and emphasized the need for enhanced validation mechanisms. Additionally, delays in processing registration requests have been identified as a barrier to timely benefits for eligible individuals.
Among the recommendations is the establishment of an Aadhaar-seeded database for beneficiaries to facilitate proper de-duplication and prompt removal of ineligible individuals. The committee also noted that only 73 percent of the target households had been registered as of November 2022, highlighting the need for more efficient registration processes.
Furthermore, the report addresses the failure of insurance companies to meet claim ratios, resulting in substantial refunds owed to the program. Of the Rs 700.10 crore recoverable, only Rs 241.91 crore has been partially recovered.
To address these issues, the committee recommends streamlining the refund mechanism, enforcing physical verification for hospital empanelment, and ensuring strict adherence to PMJAY guidelines across all states.
The findings underscore the urgent need for systemic improvements in the Ayushman Bharat scheme to prevent financial mismanagement and ensure that benefits are accurately and fairly distributed to those in need.
