Public health schemes like Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) and the Chief Minister Health Insurance Scheme (CMHIS), aimed at providing affordable medical care to underserved communities, has come under scrutiny following allegations of malpractices.
Reports of irregularities in implementation, mismanagement of funds, and exploitation of beneficiaries have raised serious concerns about the effectiveness and integrity of these initiatives.
Talking to Nagaland Post, Nagaland Health Protection Society (NHPS) chief executive officer (CEO) Thavaseelan K said that the society has put a hold on some payments under PM-JAY and CMHIS for further verification.
Thavaseelan said the insurance company Future Generali India (FGI) had submitted extensive dossiers alleging some empanelled healthcare providers of manipulation, misuse, and malpractice under the schemes.
While he did not name the hospitals involved, he mentioned that the state medical committee held a meeting on January 10 to discuss the matter. He said the claims would be thoroughly vetted and disciplinary action would be taken against the hospitals involved if found true, including their debarment.
He said that if the fraud was confirmed, the amounts paid would be recovered, and appropriate actions, including debarment of hospitals involved in abusing the scheme, would be taken.
He disclosed that around Rs 87 crore had already been paid, with 33,700 beneficiaries having received the benefits under the PM-JAY and CMHIS.
While the scheme was benefiting many people, he maintained that some people could not be allowed to misuse the schemes and claim undue benefits.
Thavaseelan said some claims were still being processed, and assured that payments would be made soon. He mentioned that the vetting process would take two to three weeks.
Assuring that the state medical committee was reviewing the situation, Thavaseelan informed this reporter that an expert committee consisting of doctors from both the government and private sectors would be formed in the next two to three weeks to examine the claims.
The CEO said the selection of committee members would be based on the specialties relevant to the most frequently occurring cases, ensuring a diverse representation of expertise, adding that the committee would review the submitted dossiers.
He said some sample cases would be investigated to determine if any malpractice or abuse had occurred.
He however pointed out that these were alleged fraud cases, and nothing could be confirmed until the investigation was complete and clear evidence found.
He disclosed that so far, 8% of the sample (around 1,000 cases) had been submitted for review. The remaining cases would also be examined. He said a press release would be issued soon, detailing how much had been paid in the past year and this year, addressing the common question about where the deducted salary funds were going.
He said the funds were used to pay premiums to the insurance company, which in turn paid the hospitals for various claims. Additionally, he mentioned that details of payments made to hospitals, both this year and last, would also be made available.
Thavaseelan admitted that miscommunication with the insurance company led to a mix-up at Faith Hospital, where a case intended for a different hospital under a separate insurance scheme was mistakenly applied to the PM-JAY and CMHIS. As a result, he explained that cashless services were temporarily suspended for nine cases, which he said was an error.
He said that once the issue was brought to their attention by some hospitals, NHPS immediately raised it with FGI, upon which the insurance company acknowledged the mistake and worked quickly to resolve it. With the issue now being addressed, he said both the hospitals were continuing the services.
He pointed out that the MoUs with empanelled hospitals clearly stated that any hospital wishing to terminate services must provide a one-month written notice. He maintained that hospitals suspending services without following this process were not adhering to the terms of the MoU.
As per the MoUs, he said hospitals should receive payments within 15 days of the following month, provided the claims were clear and genuine. However, when suspicious claims arose, he maintained that it was their responsibility to investigate. He assured that if the claims were verified as legitimate, the insurance company would ensure full payment.
Regarding delays, CEO acknowledged the challenges due to the large number of claims, but said the insurance company had now submitted a detailed dossier, and only 8% out of 33,000 cases had been audited so far, numbering 1,000 cases.
He revealed that a detailed dossier has been received for around 1,000 cases, which included information on where abuses might have occurred. Some of these cases could involve older claims, where hospitals reported not receiving payment, while the insurance company claimed payments were made. To resolve this, he said a reconciliation process was underway.
He mentioned that the insurance company had been instructed to work directly with the hospital authorities to provide transaction details, including the UTR number, to ensure everything was reconciled.
He said in cases where specific claims were in question, hospitals had been asked to provide further details. He stated that some claims were delayed due to missing supporting documents.
He stated that an official memo (OM) was issued in December, giving hospitals a deadline up to December 31 to submit any missing document or address outstanding queries. Many documents were received in the last 10 days of December, and those claims were now being processed.
Schemes operational, says NHPS: Meanwhile, Nagaland Health Protection Society (NHPS) has assured that services under the PM-JAY) and CMHIS by empanelled hospitals were fully operational, and had not been suspended.
Reacting to recent concerns regarding the suspension of services under both the schemes by certain empanelled hospitals, NHPS chief executive officer (CEO) Thavaseelan K issued a statement clarifying that there was a miscommunication from the insurance company (FGI), which had now been resolved.
He said all empanelled hospitals had been informed that these services would continue without interruption, adding that the PM-JAY and CMHIS services remained active unless a hospital unilaterally decided to suspend them, which would be in violation of the Memorandum of Understanding (MoU) signed.
Thavaseelan disclosed that altogether Rs 53.64 crore for claims under PM-JAY and CMHIS (General), and Rs 34.54 crore claims under CMHIS (EP) had been paid to various empanelled hospitals in 2023-24. For the current fiscal year 2024-25, he mentioned that Rs 38.92 crore for claims under PM-JAY and CMHIS (General) and Rs 33.52 crore under CMHIS (EP) had already been disbursed within Nagaland.
Likewise, claims paid for treatment availed outside Nagaland amounted to Rs 3.99 crore under PM-JAY, and Rs 3.81 crore under CMHIS (EP) in 2023-24, and Rs 1.95 crore under PM-JAY and Rs 10.16 crore under CMHIS (EP) for 2024-25.
Thavaseelan claimed that the utilisation of premiums was growing annually at a compounded rate of 17%, reflecting the increasing popularity of these schemes that benefited patients across the state.
However, he acknowledged that there had been reports of alleged fraud and abuse/misuse, including financial exploitation of vulnerable patients by certain empanelled hospitals. He said such practices jeopardised the sustainability of’ these schemes.
He mentioned that the department concerned had initiated investigation to examine all such allegations and ascertain the commitment of any fraud or abuse by hospitals, warning that strict actions would be taken against any hospital found violating guidelines or statutory compliance.
The CEO assured that the insurance company (FGI) was committed to release the claims amount of genuine cases.
Further, Thavaseelan reiterated that both PM-JAY and CMHIS schemes provided cashless services for beneficiaries at empanelled hospitals, and beneficiaries were not required to make any upfront payment for treatments covered under the schemes unless the patients asked for services not entitled.
Instead, he said the treatment costs were directly settled between the empanelled hospital and the insurance company, which ensured that financial barriers did not prevent eligible households from accessing quality healthcare services.
Urging beneficiaries to verify their eligibility and visit any empanelled hospital for cashless treatments, he said they could also contact the toll-free helpline number 1800-202-3380 for further assistance.
Thavaseelan advised all stakeholders, including hospitals, not to issue hasty notices regarding service suspension without confirmation from the competent authority, pointing out that such actions could cause unnecessary confusion among the public. He also encouraged citizens concerned to report any unethical practices by hospitals.
Saturday, July 5, 2025