In a significant move to uphold the integrity of the AB-PMJAY (Ayushman Bharat Pradhan Mantri Jan Arogya Yojana), 12 hospitals across the country have been de-empanelled so far in 2024. These hospitals faced action for violating guidelines, engaging in fraudulent activities, or failing to meet the quality and ethical standards mandated under the scheme, according to ET Healthworld.
Recently, five hospitals in Gujarat have been de-empanelled from the Pradhan Mantri Jan Arogya Yojana (PMJAY) due to allegations of irregularities in their operations. The hospitals reportedly engaged in fraudulent practices, such as submitting inflated or false claims for reimbursements. Two doctors associated with these hospitals have also faced action. These measures are part of ongoing efforts to maintain transparency and integrity within the scheme.
The irregularities were identified during routine audits and investigations conducted by the National Health Authority (NHA) and state health departments. As a result, these hospitals are now barred from providing services under PMJAY, ensuring that public funds are protected and appropriately utilized.
The decision comes as part of the government’s zero-tolerance policy towards misuse of the flagship healthcare initiative, which provides cashless treatment of up to ₹5 lakh per family annually for secondary and tertiary care. Over 30,000 hospitals, including public and private institutions, are empanelled under the scheme to ensure accessibility to quality healthcare.
Reasons for De-empanelment
- Instances of fraudulent claims.
- Non-adherence to scheme protocols and ethical standards.
- Discrepancies in treatment records and billing practices.
Impact of the Action
The de-empanelment reinforces the government’s commitment to transparency and accountability, safeguarding beneficiaries from malpractice. It also sends a strong message to all empanelled institutions to maintain compliance with PMJAY’s guidelines.
The National Health Authority (NHA), which administers the scheme, has been actively monitoring hospitals through audits and surprise checks to ensure beneficiaries receive genuine services.
Guidelines of De-empanelment of the Hospitals
The de-empanelment of hospitals under the Pradhan Mantri Jan Arogya Yojana (PMJAY) is governed by specific guidelines to ensure accountability and quality in healthcare services. Here’s an overview of the process and criteria:
De-empanelment Process:
- Monitoring and Complaints: State Health Agencies (SHAs) or National Health Authority (NHA) monitor hospitals for compliance with empanelment conditions. Complaints, audits, or non-compliance reports can trigger the process.
- Investigation: The District Empanelment Committee (DEC) or other authorized bodies review the allegations, conduct field verifications, and examine documentary evidence.
- Recommendations: DEC submits its findings to the SHA, recommending action, which could include de-empanelment.
- Final Decision: The State Empanelment Committee (SEC) decides whether to de-empanel based on DEC recommendations.
- Appeal Mechanism: Hospitals can appeal against the decision through specified channels.
Common Grounds for De-empanelment:
- Non-compliance with minimum criteria, such as inadequate infrastructure or manpower.
- Fraudulent practices, including overcharging, false claims, or unethical behavior.
- Failure to adhere to the terms of the Memorandum of Understanding (MoU).
- Poor service quality or breach of patient safety norms.
Institutional Roles:
- SHA: Manages the de-empanelment process at the state level and ensures transparency.
- DEC: Conducts investigations and verifications.
- SEC: Oversees and finalizes the decision-making process
Detailed Guidelines:
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