The latest report said that, in Gujarat, a total of 9 doctors and 71 hospitals have been suspended under the Union government’s flagship health insurance scheme which provides hospitalisation coverage for secondary and tertiary care services worth up to Rs 5 lakh.
The government told the committee, headed by Samajwadi Party MP Ram Gopal Yadav, that it had taken “suitable actions”, including de-empanelment of 1,113 hospitals across states. It also imposed a penalty worth Rs 122 crore on 1,504 errant hospitals.
Additionally, overall 596 hospitals have been suspended under the scheme. It did not give details of the actions undertaken in other states.
“Further, guidelines have been issued for medical camps conducted by empanelled hospitals under AB-PMJAY, mandating prior intimation to the district health officer, the presence of a government medical officer, and prohibiting enrolment activities,” the report said.
Additionally, new state-specific triggers have been implemented to enhance oversight.
“To further curb misuse and abuse of the scheme, additional pre-investigation documents have been made mandatory for pre-authorisation in cardiology and pediatric procedures,” the Centre said in the context of Gujarat fraud cases.
Cardiology-related procedures have been among the highest-utilised services under the scheme, implemented in the country in 2018.
The parliamentary committee said that the National Health Authority (NHA)—the department that runs the AB-PMJAY—should go beyond reacting to reported fraud by continuously analysing claim data, hospital activity, and patient feedback to identify statistical anomalies and emerging trends indicating potential abuse.
Specifically, the NHA should develop and publicly report on 155 key performance indicators related to fraud detection, including the frequency of pre-authorisation requests for specific procedures, the ratio of medical camp referrals to hospital admissions, and the rates of hospital de-empanelment and penalties by state.
It further suggested that in the collection and analysis of statistical data and feedback, the extensive use of artificial intelligence and digital tools should be considered.
“This transparent, data-driven approach will not only allow for quicker intervention but also serve as a deterrent, ensuring the scheme’s resources are used for their intended purpose and maintaining public trust,” it noted.
Independent experts meanwhile stressed that a crucial scheme such as AB-PMJAY must be evaluated in every state for its benefits related to financial protection and implementation on the ground.
“AB-PMJAY, like almost every other health insurance in the country, has been shown to be prone to frauds by private hospitals despite the anti-fraud measures that the government keeps talking about. The scheme therefore needs to be thoroughly audited by academicians and independent entities,” said public health expert Amulya Nidhi.
Around 12.3 crore families of poor socio-economic status have been covered under the programme so far. The scheme since late last year also covers those aged 70 and above, irrespective of their income status.
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Underutilisation of funds
In 2023-24, according to the report, an amount of Rs 7,200 crore was allocated which was reduced to Rs 6,800 at the revised estimate (RE) stage. However, the actual expenditure was Rs 6,670.47 crore.
In 2024-25, a sum of Rs 7,300 crore was allocated for the scheme which was revised to Rs. 7,605.54 crore at RE. The actual expenditure was to the tune of Rs. 5,034.03 crores till 1 January this year.
In the upcoming fiscal, an enhanced amount of Rs. 9,406 crore has been allocated for the programme.
“This indicates potential inefficiencies in fund disbursement or implementation bottlenecks. The Committee, therefore, recommends a thorough review of the fund release mechanisms to states,” noted the report, adding that the review should focus on identifying and eliminating bottlenecks that contribute to underutilisation.
Specifically, the NHA should implement a system of proactive monitoring of fund utiliSation by states, coupled with targeted support to address any implementation challenges, the committee said.
This support could include technical assistance, capacity building, and simplified reporting procedures.
“Furthermore, the committee suggests that the release of funds be linked to the performance of states in terms of card creation, hospital admissions, and beneficiary feedback, ensuring that funds are directed to areas of greatest need and impact,” it also said.
The department should also create and publish a clear and concise guideline for states, explaining the process of fund requests, and the expected timelines.
To ensure that the funds allocated in 2025-26 are fully utilised, the committee recommended the set up of a quarterly review system be set up to avoid any delays in the release of funds to states.
It also recommended raising the coverage limit under the programme from Rs 5 lakh to Rs 10 lakh and extending the coverage to all aged 60 years and above, irrespective of their income status.
But public health experts, such as Dr T. Sunadraraman, who has previously headed the Union government’s National Health System Resource Centre, underlined that while the latest report has identified some problems in the implementation of the AB-PMJAY, it has not gone into how and why.
“If the underutilisation of funds for the AB-PMJAY is a problem—which is a minuscule percentage of the health budget, the committee should have assessed why it is so and how that can be fixed. The suggestions given are rather weak,” said Sundararaman.
(Edited by Sanya Mathur)