CAG revealed that beneficiaries paid money for treatment under Ayushman Bharat health scheme

New Delhi: In its performance audit report on the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), the Comptroller and Auditor General of India (CAG) revealed that beneficiaries paid money for treatment despite the scheme intending to provide cashless services.

The AB-PMJAY provides a health cover up to Rs 5 lakhs per family per year, for secondary and tertiary care hospitalisation services.

It provides cashless and paperless access to services for the beneficiaries at the point of service -- hospital.

The CAG’s audit report on AB-PMJAY which was presented in Parliament recently, said: "The agreement signed by the SHA (State Health Agency) and the private EHCPS (Empanelled Health Care Providers) states that the treatment/interventions to PMJAY beneficiaries should be provided in a completely cashless manner.

"After admission of a patient in hospital, expenditure for all diagnostic tests, medicines, implants, etc is to be borne by the hospital since the costs for the same have been included in the cumulative package amount. However, audit noticed instances where patients had to pay as part of their treatment under the PMJAY.

"In Himachal Pradesh, 50 beneficiaries of five EHCPs had to manage their diagnostic tests from other hospital/diagnostic centre and cost of tests was borne by the beneficiaries. The amount of expenses was not available with the SHA."

The report further revealed that at 10 public EHCPs in Jammu and Kashmir, 459 patients paid Rs 43.27 lakhs initially out of their own pocket for which reimbursement was made to the patients after verifying the bills.

Reimbursement is yet to be made to 75 patients amounting to Rs 6.70 lakhs.

"In Jharkhand, the insurance company observed that 36 patients of Life Care Hospital, Godda paid varying amounts for purchase of medicines, injections, blood, etc. The details of expenses were not available with the SHA. On the basis of the insurance company's observation, SHA (on August 28, 2020) asked the hospital to submit its explanation within five days to avoid a penalty, failing which the hospital would be suspended. However, the hospital neither submitted any explanation, nor did the SHA initiate any action against the hospital," the CAG report said.

In Meghalaya, out of 19,459 beneficiaries who availed treatment in five private EHCPs from February 2019 to March 2021, 13,418 (69 per cent) had to pay an additional amount of Rs 12.34 crore at the time of discharge, it added.

"In August, 2022, NHA replied that the out-of-pocket expenditure may be due to non-availability of health facilities.Audit is of the opinion that the hospitals should collaborate with various interrelated service providers to provide free facilities to the beneficiaries.