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Home Health Ayushman Scheme: Fraudulent Practise

Ayushman Scheme: Fraudulent Practise

Ayushman Scheme: Fraudulent Practise
An AB-PMJAY seeker waits for the verification process to get over/Photo:
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Above: An AB-PMJAY seeker waits for the verification process to get over/Photo:

The Prime Minister’s Ayushman Bharat Scheme is riddled with dishonest practices by hospitals and common service centres, leading to their de-empanelment and FIRs being lodged


By Dr KK Aggarwal

Trust Indians to find innovative ways to beat any system. The National Health Authority (NHA), the nodal agency for the government’s health insurance scheme, has found that hospitals and common service centres (CSCs) have found ways to beat the centrally-sponsored Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) system.

Over 250 hospitals out of 15,955 (7,992 private and 7,963 public) have been de-empanelled for fraudulent practices and FIRs registered against CSCs for fudging beneficiary data. In Agra district, 900 CSCs and in Pilibhit district three CSCs were deactivated and FIRs lodged against the CSC in-charge.

Though this scheme was introduced for the benefit of all and as many as 30 lakh people have availed of it, fraudulent practices are giving it a bad name. The fraud being perpetrated is seeing many forms:

  • A single doctor conducting surgeries in four districts on the same day (ghost charges).
  • Patients being charged for expensive procedures not conducted on them.
  • Multiple surgeries conducted on a single day late in the night.
  • Hysterectomies on men.
  • Fake beneficiaries issued cards by CSCs.
  • Ineligible persons colluding with CSCs (authorised to identify beneficiaries under the Ayushman Bharat scheme) to deprive real beneficiaries.
  • Unnecessary expensive procedures being conducted on patients who did not require them so that the hospital can tap into higher packages’ reimbursement.
  • Ghost patients being referred to private hospitals by government doctors. The money meant for the treatment of these non-existent patients is then pocketed by the government doctors.
  • Nexus between staff in government and private hospitals. Patients who visit the government’s primary health centres need a referral slip when they are sent to a private hospital. The staff has been charging bribes to issue these slips.

The AB-PMJAY system automatically detected a sudden spurt in similar procedures in a single day in the same hospital. The Insurance Regulatory and Development Authority of India and NHA have formed a working group on PMJAY. The group, to be chaired by Dinesh Arora, Deputy CEO, NHA, will have ten members from both the organisations. In six months, it will submit a report on how to detect and deter fraud through a common repository.

The nobility of the medical profession requires zero tolerance for corruption. MCI ethics regulation 7.7 clearly says that the name of a person can be deleted from the register and his licence to practise cancelled permanently in such cases. It says: “Registered medical practitioners are in certain cases bound by law to give, or may from time to time be called upon or requested to give certificates, notification, reports and other documents of similar character signed by them in their professional capacity for subsequent use in the courts or for administrative purposes, etc. Such documents, among others, include the ones given in Appendix-4. Any registered practitioner who is shown to have signed or given under his name and authority any such certificate, notification, report or document of a similar character which is untrue, misleading or improper, is liable to have his name deleted from the Register.”

Regulation 1.7 also talks about exposure of unethical conduct: “A physician should expose, without fear or favour, incompetent or corrupt, dishonest or unethical conduct on the part of members of the profession.” Regulation 6.4 clarifies commissions in such situations: “6.4.1 A physician shall not give, solicit, or receive nor shall he offer to give, solicit or receive, any gift, gratuity, commission or bonus in consideration of or return for the referring, recommending or procuring of any patient for medical, surgical or other treatment. A physician shall not directly or indirectly, participate in or be a party to act of division, transference, assignment, subordination, rebating, splitting or refunding of any fee for medical, surgical or other treatment.”

Provision 6.4.2 says that provisions of 6.4.1 shall apply with equal force to the referring, recommending or procuring by a physician or any person, specimen or material for diagnostic purposes or other study/work.

Fraud can be of two types—Intentional (Fraud) and Unintentional (abuse), according to the American Medical Association Ethics. These are manifested in many ways, especially in the coding of bills. For example:

  • When there is a single billing code available that captures payment for the component parts of a procedure that should be used instead of unbundling them. This refers to using multiple billing codes for those parts of the procedure, either due to misunderstanding or in an effort to increase payment. This can include charging for hysterectomy, oophorectomy (surgical removal of the ovaries) and vaginal repair separately when pan-hysterectomy billing is available.
  • Charging as new a reused or disposable device.
  • Charging for high-priced antibiotics which were not used.
  • Upcoding: Charging for a major time intervention when there was only a minor time one. For example, the doctor may have met a patient for a few minutes about a routine question but the coder bills for a full examination lasting 45 minutes.
  • Charging for two procedures on the same day—e.g., you bill for a lesion excision and skin repair on a single date. Most simple repairs are included in the excision billing code, so separately coding the repair would be wrong. But if the repair was performed on a different site from where the lesion was removed, it is ok to bill for both and append a modifier to let the payer know the procedure was separate from the excision.
  • One must include proper documentation to explain why the procedure requires more work and investigations. For example, if you excise a lesion on the crease of the neck of a very obese patient, one must explain that obesity makes the excision more difficult.
  • Good documentation of the start and stop times are essential for medical coders to properly bill for these services.
  • Charging for multiple sessions of injections. One must report one billing code for the entire session during which the injections take place instead of multiple units of a code. For example, if continuous intravenous hydration is given from 11 pm to 2 am, two administrations will be abuse of billing.
  • Reporting unlisted codes without documentation. If you must use an unlisted code to properly bill for a service, you must properly document it.

Honesty is the best policy and if that is not understood by medical providers, punishment is a natural consequence.

—The writer is President, Heart Care Foundation of India, and President-elect, Confederation of Medical Associations of Asia and Oceania

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