New Delhi: A House panel has observed inadequacies in identifying and verifying beneficiaries under the Ayushman Bharat-Pradhan Mantri Jan Aarogya Yojana (PMJAY), leading to delays in removing ineligible beneficiaries and registering new ones.
The observations, made by the Public Accounts Committee (PAC) in its PMJAY performance audit, come at the back of a 2023 audit report by the Comptroller and Auditor General of India (CAG) flagging claims for treatment of the dead and several registrations on the same Aadhaar.
The PMJAY, a flagship health insurance scheme by the Narendra Modi government, provides secondary and tertiary care hospitalisation benefits of up to Rs 5 lakh to the poor.
The PAC said the Union health ministry should find ways and measures to update the coverage of the PMJAY beneficiaries without compromising the process. It also recommended the constitution of an independent body to oversee this process, based on an authentic database. Moreover, it suggested the ministry and states devise a suitable mechanism to identify persons eligible for the scheme state-wise in a time-bound way.
The report flagged that a delay in removing ineligible beneficiaries led to them receiving benefits under the scheme, resulting in excess premium payments to insurance companies. To tackle this, the PAC suggested validation checks as an inbuilt feature of the registration process to avoid invalid entries and increase the accuracy and reliability of the data.
The PAC also observed from the CAG audit that requests for registration under the scheme were followed by inordinate delays, resulting in the denial of benefits to potential beneficiaries. As a way around this, it asked the Union health ministry to ensure that the registration process is streamlined to help avoid delays beyond the prescribed time.
ThePrint contacted the Union health secretary over the phone for a comment on the PAC report. This report will be updated if and when a reply is received.
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Issues in empanelment, quality check
The PAC noted from the CAG audit that in 12 states and Union Territories, some of the hospitals empanelled under the scheme did not meet the minimum criteria for empanelment due to deficiencies. These include out-of-order medical equipment, and a lack of basic infrastructure such as in-patient beds, operation theatres, intensive care with ventilator support systems, pharmacy, dialysis unit, or other services.
On its part, the PAC has recommended a mandatory physical verification process for the empanelment of hospitals so that only those that fulfil the requisite criteria are empanelled.
The PAC also observed that the availability of empanelled healthcare providers is “very low” per lakh population in several states/UTs even though state governments are meant to ensure that the maximum number of eligible hospitals participate in PMJAY.
To build an effective and accountable network of health service providers of standard quality, authorities should encourage more private hospitals to join the scheme in all districts while upgrading facilities in public hospitals, the PAC said further.
The PAC also noted that the National Health Authority (NHA), which implements the PMJAY, has specified a time limit for settling claims.
However, for reasons such as the non-release of states’ share of funds on time, lack of trained human resources, nonperformance of implementing support agency or pendency at the hospital end in replying to claims-related queries, there have been delays in claim settlements in several cases, it said.
The PAC also noted that the NHA released excess implementation grants to some states — a violation of the prescribed guidelines.
“The committee is not convinced with the NHA’s justification for the excess release of grants as the release of funds in contravention of guidelines undermines the integrity of financial management and calls into question the NHA’s commitment to compliance,” said the report.
It recommended that the NHA release implementation grants to states, strictly in tune with PMJAY guidelines, justify any exceptions based on clear and transparent criteria, and take prior authorisation from the competent authority.
(Edited by Madhurita Goswami)
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