U’khand only state in India where all families are under a health insurance cover of Rs 5 lakh
In absence of a proper governing mechanism and shortage of staff, the Atal Ayushman Uttarakhand Yojana (AAUY), the flagship health scheme of Trivendra Singh Rawat has become prone to corruption and fraudulent claims.
The dream project of CM Rawat under which the covered family members can avail the benefit of free treatment up to Rs 5 lakh per year has become a hotbed of corruption in which the state health agency (SHA) entrusted with the task of implementing and steering the project is stumbling upon cases of corruption with alarming regularity. Most of these cases are involved with claim settlement. Interestingly the SHA lacks a proper mechanism and set of operating procedure to deal with cases of irregularities.
In a recent case, the authorities of AAUY found gross anomalies in claims made by S P Memorial hospital, Kashipur in Udham Singh Nagar district. On investigation it was found that the hospital had an Intensive Care Unit (ICU) of 10 beds but it was regularly showing 11 to 20 patients in ICU on many days. In its bid to extract maximum money by fraudulent claims, the hospital also made the mistake of initiating pre authorization after discharge of the patients and got caught.
In another case, a gynaecologist working on contract in a government hospital in Kashipur was referring patients to a private hospital in Kashipur which happens to be owned by her husband. In a similar case, a private hospital in Sultanpur Haridwar was found to be unduly favoured by a doctor deployed in the Government hospital Raisi in Haridwar.
Acting on the malpractices and the complaints made by the patients, the state health agency has so far initiated action against 14 hospitals. It has suspended empanelment of 11 hospitals and initiated legal process of recovering claims from Astha hospital Kashipur, Udham Singh Nagar and Priya hospital Haridwar.
The agency has so far detected irregularities in about 2000 claims so far but experts believe that the figure is much higher as many malpractices have simply gone unnoticed by authorities. In the SHA, the posts of director Information Technology and Director Vigilance are lying vacant and in absence of trained manpower, the agency has to remain dependent on the private agency hired for claim settlement for many important things.
The Chairperson of the SHA, D K Kotia admits shortage of staff but added that the utmost vigilance is being made so that public money is not wasted. He said that a State Anti Fraud Unit (SAFU) is working round the clock to check discrepancies. Kotia said that legal proceedings are being initiated against the culprits and recovery of the fraudulent claims would be done.
AAUY was launched amid much fanfare, on December 25, 2018 by the chief minister Trivendra Singh Rawat. In the scheme, the Uttarakhand CM provided a health insurance cover of Rs 5 lakh per annum to all 23 lakh families of Uttarakhand in the empanelled hospitals. Incidentally Uttarakhand is the only state where all families are under the health insurance umbrella of the state government. In AAUY the patients can avail benefit of the scheme for 1350 types of diseases in the empanelled hospitals.
Flaws in referral system
For treatment in the private empanelled hospitals, the patients are needed to be referred from the government hospitals. As per the provisions of the scheme, the patients should be referred only when the required treatment is not available in the government centres. However in absence of any set of guidelines this system of referral is being used to defraud the scheme. The SHA is now working on developing a Standard Operating Procedure (SOP) to streamline referral system.
Fact-file: Atal Ayushman Uttarakhand Yojana
Launch date- 25 December 2018; Insurance cover- Rs 5 lakh per year per family; Diseases covered- 1350; Empanelled hospitals – 156; Total approved cards- 3213873; Number of Patients treated-48613; Total Claim amount- Rs 485664463
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