Major Discrepancies In PMJAY Scheme From Fake Beneficiaries To Faulty Implementation: CAG Report

On Tuesday, the Comptroller and Auditor General of India tabled its 'Performance Audit of Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana' report in the parliament. The report has revealed major discrepancies subsuming fake beneficiaries using the same IDs for multiple uses, unqualified hospitals empanelled under the PMJAY scheme, inconsistency in claim settlements and financial management and insufficient grievance redressal mechanisms across the country. 

Launched in 2018 the Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) scheme aims to provide health cover of Rs 5 lakh per family per year for secondary and tertiary care hospitalisation to over 10.74 crore families from poor and vulnerable section of the population, based on the deprivation and occupational criteria of the Socio-Economic Caste Census (SECC), 2011.

The eligible beneficiaries are entitled under AB-PMJAY to cashless and paperless access to services at the empanelled hospitals. Although contrary to popular claims made by the Union Government the CAG report highlighted major disparities, the CAG report revealed that the registration of multiple beneficiaries against the same or invalid mobile number ranging from 11 to 7,49,820 beneficiaries was noted in the Beneficiary Identification System (BIS). 

Further in 36 cases, two registrations were made against 18 Aadhaar numbers and in Tamil Nadu, 4761 registrations were made against seven Aadhaar numbers.

"The match confidence score, which the online system of beneficiary registration, generates based on matching the documents of a beneficiary with the SECC list of eligible beneficiaries, has been rendered ineffective as applications for registration were approved or rejected irrespective of the match confidence score," the CAG report said. 

Data analysis revealed that a match confidence score was not applied during the approval and rejection process of the registration of a person.

The report also revealed that ineligible households were found registered as PMJAY beneficiaries and had availed benefits of the Scheme. The expenditure on these ineligible beneficiaries ranged from Rs 0.12 lakh in Chandigarh, to Rs 22.44 crore in Tamil Nadu.

Inefficient Hospitals Empaneled Under PMJAY

The CAG report noted that several States and UTs had a shortage of infrastructure, equipment, doctors, etc and the available equipment was found non-functional. "Some of the Empanelled Health Care Providers (EHCPs) neither fulfilled minimum criteria of support system and infrastructure nor conformed to the quality standards and criteria prescribed under the Guidelines," the report pointed out. 

The report further found that mandatory compliance criteria relating to infrastructure, fire safety measures, Bio-medical waste management, Pollution Control and Hospital registration certificate were not fully followed.

"Physical verification was not conducted by District Empanelment Committee (DEC) before empanelment in 163 EHCPs in Manipur (17), Tripura (103) and Uttarakhand (43)," the report revealed. 

Further, the report found many cases where beneficiaries are not being treated by the empanelled hospitals for certain specialities which are available to the general public. 

"In Jharkhand, two private EHCPs were not providing three specialities under the PMJAY, which were otherwise available for the general public. In Assam, 13 EHCPs were providing 4 to 80 per cent of available facilities to PMJAY beneficiaries," the report disclosed. 

The report noted that 126 EHCPs treated beneficiaries for non-empanelled specialities and in 647 empanelled hospitals no treatment was provided. In four States 13,963 beneficiaries were charged for their treatment in empanelled EHCPs resulting in an increase in out-of-pocket expenditure of beneficiaries. 

Claim Settlement Mismatch

Many discrepancies such as invalid dates of admission, pre-authorisation, claim processing, and non-availability of certain crucial dates were noted in the report. Instances such as the date of surgery being after the date of discharge of the patient, invalid or null entries in the patient age column, the date of discharge being earlier than the admission date and allowing the pre-authorisation request of treatment of a beneficiary shown as ‘died’ in many cases were reported.  

Data analysis revealed that 39.57 lakh claims took more than the specified time of 12 hours to approve pre-authorisation. While in four States, excess payments amounting to Rs 57.53 crore were made to the EHCPs. 

In several States and UTs revenue received from PMJAY was not utilised by government hospitals for the purpose defined under the scheme, the report found. 

"In Andhra Pradesh and Punjab, private hospitals were performing procedures reserved for public hospitals. In six States and UTs, there was a delay in the submission of claims by hospitals and payment was made to hospitals without any penalty and even inadmissible payments were also made to these hospitals," the CAG report said. 

Penalty amounting to Rs 12.32 crore from 100 hospitals was pending in nine States and UTs. State Health Authorities (SHAs) in Jammu & Kashmir and Ladakh failed to levy penalties amounting to Rs 20.93 crore and Rs 39.66 lakh respectively on the Insurer for non-performance of various activities. 

Irregular Financial Management

SHAs furnished Utilisation Certificates (UCs) without audit and the signature of competent authority while also inflating UCs than the actual amount, CAG said.  

"18 SHAs furnished 212 Utilisation Certificates (UCs) amounting to Rs 4,115.35 crore without audited statements of accounts during 2018-21. Out of these 18 SHAs, seven SHAs furnished UCs without the signature of the competent authority. Six SHAs furnished to NHA, inflated Utilisation Certificates amounting to Rs 38.24 crore," the report noted.

10 States did not remit the interest of Rs 22.17 crore earned by them on unspent grants to NHA. While Rs 458.19 crore was recoverable from the insurance companies in six States and UTs. The State of West Bengal withdrew from PMJAY in January 2019 but did not refund Rs 31.28 crore to NHA, the report found. 

Absent Grievance Redressal Systems

The CAG report brought to light that out of 37,903 grievances, only 3,718 complaints (9.80 per cent) were redressed within turn - around-time while 33,100 complaints (87.33 per cent) were redressed beyond turn-around time. And 1,085 complaints were under process for redressal. 

In five States and UTs, District Implementing Units (DIUs) had not been formed by SHAs. In Tripura, DIUs have only been constituted in five Districts. While in 22 States and UTs, a shortage of manpower at various posts in SHAs and DIUs were noticed. 

In Chhattisgarh and Manipur, District Grievance Redressal Committees (DGRCs) have not been constituted in some districts. In Jharkhand, DGRCs have been constituted with delay. In Ladakh and Madhya Pradesh, DGRCs were not constituted at all.

"In six States/UTs, no meeting of DGRC was held while in three States, shortfalls in meetings of DGRC were 53 to 100 per cent," the report said.