Due to the absence of adequate validation controls, the beneficiary database of Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) contains several errors like invalid names, unrealistic date of birth, duplicate PMJAY IDs and unrealistic size of family members in a household, says an audit report from the Comptroller and Auditor General of India (CAG) submitted in the Parliament
. Further, ineligible households were found registered as PMJAY beneficiaries and had availed the benefits ranging between Rs12,000 and Rs22.44 crore under the scheme.
According to the performance audit, nearly 750K (thousand) beneficiaries of PMJAY were found registered with a single mobile number, 9999999999. Over 139K beneficiaries used 8888888888, while 96,046 have used 9000000000 as their mobile number while registering for the Ayushman Bharat scheme. There were also at least 20 mobile numbers to which between 10,001 and 50,000 beneficiaries were linked.
In 36 cases, two registrations were made against 18 Aadhaar numbers and in Tamil Nadu, 4,761 registrations were made against seven Aadhaar numbers. In Jammu & Kashmir (J&K) and Ladakh, between 2018 to 2021, 16,865 and 335 ineligible beneficiaries, respectively, were identified by the state health authorities (SHAs) after cleaning the socio-economic caste census (SECC) data.
"Data analysis of BIS database revealed that there were large numbers of beneficiaries registered against the same or invalid mobile number. Overall 11 to 7,49,820 beneficiaries were linked with a single mobile number in the beneficiary identification system (BIS) database," CAG says.
While agreeing with the audit observation, NHA told CAG in August last year that with the deployment of BIS 2.0, this issue would be resolved. Further, the BIS 2.0 system has been configured so that more than a certain number of families cannot use the same mobile number. This will arrest the prevalence of entering random numbers, which constitute overwhelming cases of mobile number inconsistency.
CAG observed that delayed action in weeding out the ineligible beneficiaries resulted in ineligible persons availing benefits of the scheme and excess payment of premium to the insurance companies.
Launched in September 2018, the AB-PMJAY aims to provide health cover of Rs5 lakh per family per year for secondary and tertiary care hospitalisation to over 107.4mn (million) families from the poor and vulnerable section of the population, based on the deprivation and occupational criteria of the SECC of 2011.
As per records from the national health authority (NHA), as of November 2022, nearly 78.7mn beneficiary households, or about 73% of the targetted households of 107.4mn, were registered under the scheme. NHA says the Union government has approved an expansion of the beneficiary base to cover 12mn families.
Commenting on hospital empanelment and management, CAG found a shortage of infrastructure, equipment, and doctors in several states and Union Territories (UTs) and 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. In several states and UTs, mandatory compliance criteria for empanelment of hospitals relating to infrastructure, fire safety measures, bio-medical waste management, pollution control and hospital registration certificate were not fully followed. In some EHCPs, fire safety certificates had expired before empanelment under PMJAY."
Further, some EHCPs did not conform to the prescribed quality standards and criteria which were crucial to the safety and well-being of the beneficiaries in care and were mandatory minimum conditions for empanelment, CAG says.
The performance audit report found that six states, which use their own information technology (IT) platform to process the claims, have settled almost 53.30% or claims worth Rs22,619.86 crore out of a total 3.57 claims worth Rs42,433.57 crore. These states are Andhra Pradesh, Arunachal Pradesh, Rajasthan, Karnataka, Maharashtra and Tamil Nadu.
According to CAG, three SHAs, Chhattisgarh, Punjab and Uttarakhand, had not maintained separate escrow accounts for PMJAY and the state-sponsored scheme. Both schemes were operated through a combined account. "In contravention of guidelines, NHA released grants of Rs280.20 crore, Rs217.60 crore and Rs112.62 crore in three different bank accounts to SHA Chhattisgarh during 2018-21.”
Further, the report says 18 SHAs furnished 212 utilisation certificates (UC) worth Rs4,115.35 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, while six SHAs furnished to NHA inflated UCs amounting to Rs38.24 crore.