A crackdown on fraud in Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) by the government has intensified in the past few weeks, with the enforcement authorities bringing down thousands of healthcare providers who are accused of violating the scheme’s operational guidelines.
According to official data available till May 31, so far more than 2,000 hospitals have been de-empanelled, and another 1,200 hospitals have been suspended from the flagship health insurance scheme following investigations into suspected irregularities.
The authorities have also filed 29 First Information Reports (FIRs) and issued financial penalties of ₹328.49 crore against hospitals and other entities that violated the scheme’s rules.
Investigators said that the actions had been taken after detailed audits and digital verification of claims under the Ayushman Bharat programme that provides cashless healthcare coverage to eligible beneficiaries in India.
Among the findings of the investigation were unauthorised billing, duplicate insurance claims, inflated medical procedures, and physician identities being exploited for fraudulent payments. The scheme lost money through these practices and did not achieve the aim of providing affordable healthcare to eligible citizens, officials said.
A major aspect of the ongoing crackdown has been the use of Artificial Intelligence (AI) and advanced data analytics to see if there are suspicious claims. AI-based monitoring systems are now able to detect potentially fraudulent claims within 24 hours of their submission and to make the claims’ verification and enforcement process more efficient, the officials said.
The AI-based fraud detection system analyses large volumes of healthcare claims based on a number of risk indicators including unusual billing practices, repetitive procedures, abnormal claim frequency, and non-matching patient records. The data that determines suspicious claims is reviewed in detail before payment is made.
Artificial intelligence has increased the government’s ability to detect fraud in real time and reduce delays in investigations, ensuring that fraudulent claims are not settled, officials said.
The Ayushman Bharat-PMJAY is the world’s largest publicly funded health insurance programme, providing health coverage of up to ₹5 lakh per eligible family for secondary and tertiary care hospitalisation. With millions of beneficiaries and thousands of empanelled hospitals around the country, transparency and preventing misuse are the two most important aspects for the implementing authorities.
The government has repeatedly put a zero-tolerance stance on fraud under the scheme. Hospitals found guilty of violating operational guidelines can be suspended, de-empanelled, face financial recovery, penalties, criminal prosecution, or other legal action depending on the severity of the violations.
Healthcare experts have welcomed the use of AI and data analytics to strengthen oversight, arguing that technology-based monitoring can increase transparency, and the quality of care is better for genuine beneficiaries while still ensuring that the real beneficiaries get access to healthcare services uninterrupted as long as they are cared for by the system.
Inspections and audits are ongoing, and digital surveillance will continue across the country, with more enforcement action expected where fraud is detected. The ongoing crackdown is to protect public funds, preserve the credibility of the Ayushman Bharat scheme, and ensure that the medical benefits for the public are available to the patients who need them without abuse or misuse.
The numbers are a reflection of the scale of enforcement efforts and the way the government is now relying on technology-enabled oversight to protect one of India’s biggest public healthcare programmes.
