The use of artificial intelligence and machine learning is made for a comprehensive fraud analytics solution to proactively detect fraud, develop algorithms that can be used on large volumes of data to identify Suspicious transactions and entities and risk rating of hospitals and claims, Lok Sabha was briefed on Friday.
Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is governed by a zero-tolerance approach to any type of fraud, such as suspicious or inauthentic medical treatment claims, identity theft and coding of treatments and procedures etc., Minister of State for Health Bharati Pravin Pawar said in a written response.
Responding to a question whether it is a fact that around 23,000 fraudulent transactions were recorded in hospitals incorporated under AB-PMJAY in 2021-22, she said the National Health Authority – AB-PMJAY’s implementing agency has issued a comprehensive set of anti-fraud guidelines.
Anti-fraud advisories are issued to states and union territories. The National Fraud Enforcement Unit is established at the NHA for the overall monitoring and implementation of the anti-fraud framework supported by state anti-fraud units at the state level.
“All claims require mandatory supporting documents along with photo of patient in bed before approval and payment. Beneficiary’s Aadhaar-based biometric verification feature at admission and discharge is launched in all private hospitals.
“The use of artificial intelligence and machine learning is made for a comprehensive fraud analytics solution to proactively detect fraud, develop algorithms that can be used on large volumes of data to identifying suspicious transactions and entities and scoring hospitals and claims risks,” Pawar said.
Providing details of action taken by state health agencies, she said Chhattisgarh accounts for the highest number of claims in which criminal charges have been brought for fraudulent hospital transactions under AB -PMJAY, followed by Madhya Pradesh, Punjab, Kerala and Jharkhand.
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