The Comptroller and Auditor General (CAG) of India's performance audit of the Ayushman Bharat-Pradhan Mantri Jan Aarogya Yojana (PMJAY), the government's health insurance scheme, revealed irregularities including patients being admitted to multiple hospitals simultaneously, hospitals exceeding their bed capacity, and claims made for deceased patients. Conducted from September 2018 to March 2021, the audit report, presented in the Rajya Sabha, acknowledged PMJAY's positive impact on vulnerable sections while highlighting areas for improvement. Issues raised encompass beneficiary identification and registration problems due to inadequate validation controls, resulting in errors like invalid names, duplicate IDs, and unrealistic family sizes. For instance, the report points out cases of multiple registrations under the same Aadhaar number, with 18 instances involving 36 registrations and 4,761 registrations tied to seven Aadhaar numbers in Tamil Nadu.
In order to avoid any further misuse of the scheme it is imperative for the government to deploy AI/ML tools on immediate basis. These cutting-edge tools have been integrated by various insurers to identify suspicious transactions and potential frauds. Strategic utilization of AI and ML will not only bolsters the scheme's integrity but also ensure that eligible beneficiaries receive the necessary healthcare services. With technology partners actively engaged in the development and deployment of anti-fraud measures, this initiative would a commendable stride in the fight against healthcare fraud.
Note: At the time of writing of this article online sources indicated utilisation of AI/ML tools by government in PMJAY however no concrete evidence could be discovered.
What is covered under Ayushman Bharat Scheme:
The National Health Authority (NHA) is responsible for implementing India’s flagship public health insurance/assurance scheme called “Ayushman Bharat Pradhan Mantri Jan Arogya Yojana” 1. The NHA is the apex body responsible for designing strategy, building technological infrastructure, and implementing “Ayushman Bharat Digital Mission” to create a National Digital Health Eco-system. The scheme aims to provide a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization to over 12 crores poor and vulnerable families (approximately 55 crore beneficiaries) that form the bottom 40% of the Indian population. The claims under Ayushman Bharat Yojana are settled by the empanelled hospitals. The hospitals are required to submit their claims to the insurance company within 30 days of discharge of the patient.
AI and ML: Pillars of Fraud Detection The Ayushman Bharat scheme, often referred to as "Modicare," is a flagship initiative by the Indian government aimed at providing healthcare coverage to millions of citizens who were previously devoid of such benefits. With a scheme of such colossal scale, it is imperative to implement mechanisms that safeguard against potential fraudulent activities that could undermine its purpose.
Benefits of AI and ML Integration:
1. Preventive Measures: The integration of AI and ML in the AB-PMJAY scheme enables proactive detection of fraudulent activities, preventing them from occurring in the first place. This preemptive approach is crucial in maintaining the integrity of the scheme. 2. Real-time Analysis: With AI and ML, transactions and claims can be analyzed in real-time. This means that any unusual or fraudulent activity can be swiftly identified, flagged, and investigated, minimizing potential financial losses. 3. Pattern Recognition: Fraudulent activities often follow distinct patterns. AI and ML algorithms can identify these patterns by comparing current data with historical records. This assists authorities in recognizing potentially fraudulent transactions.
The Role of Technology Partners Technology partners would play a pivotal role in the successful implementation of AI and ML technologies for fraud detection under the Ayushman Bharat scheme. These partners can be tasked with developing and deploying anti-fraud measures that leverage the power of AI and ML. Their expertise ensures that the technology is tailored to the specific needs of the healthcare sector, making it more effective and adaptive to emerging fraudulent techniques.
Quantifying Success
As of August 1, 2023, an impressive total of 24.33 crore Ayushman cards have been issued under the scheme. This reflects the substantial impact and reach of the program. The integration of AI and ML in fraud detection would serve as an additional layer of security that safeguards the interests of both the beneficiaries and the government.
Conclusion Effective integration of AI and ML technologies in the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana would mark a significant step forward in the fight against healthcare fraud. These technologies serve as powerful tools that not only detect potential frauds but also act as deterrents, ensuring the scheme's resources are optimally utilized for the benefit of the deserving beneficiaries. With ongoing advancements in technology and collaboration between government bodies and technology partners, the Ayushman Bharat scheme sets a commendable precedent for leveraging AI and ML in social welfare programs
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