Trigger prompts formation of 4-member committee
Irfan Tramboo
Srinagar, June 16: The State Health Agency (SHA) of J&K has established a four-member committee to probe alleged fraudulent activities in the filing of insurance claims under the Ayushman Bharat Jan Arogya Yojana (AB PMJAY-SEHAT) scheme at Government Medical College (GMC) in Baramulla.
An official order issued by the SHA stated, “The State Health Agency (SHA), J&K, received a trigger regarding suspected fraudulent activity at Government Medical College, Baramulla.”
To look into the matter and to see if the allegations are correct or not, the SHA formed a 4-member committee comprising Dr Bashir Ahmad Malik, Chief Medical Officer of Baramulla; Dr Misbah Samad, State Medical Officer at SHA J&K; Dr Wasim Akram, State Anti-Fraud Officer at SHA J&K, and representative from IFFCO Tokio, GIC—the insurance company.
The SHA has emphasized that the committee is required to submit a detailed report within 10 working days from the issuance of the order.
Officials, while speaking to Excelsior, confirmed that there were indications of fraudulent activities and that the matter was being thoroughly investigated to ascertain the veracity of the alleged frauds. However, they refrained from providing specific details at this time.
Those familiar with the matter have revealed that fraudulent activities in such cases are typically flagged by the insurance company when they raise queries regarding claims which appear to be suspicious. These queries serve as triggers that prompt further investigation.
If the responses provided by the concerned parties fail to satisfy the insurance company’s concerns, they said, the matter is escalated to the State Anti-Fraud Squad. The squad’s primary responsibility is to validate the authenticity of the flagged claims and recommend the necessary action in cases where the frauds turn out to be valid.
“The State Anti-Fraud Squad is dedicatedly working on such cases and has, thus far, uncovered several instances of fraud occurring in empanelled hospitals under the AB PMJAY-SEHAT scheme,” said the officials.
They further explained that several cases, especially those related to surgeries, have emerged from private empanelled hospitals and upon closer examination and auditing, fraudulent activities were discovered, leading to penalties being imposed on the hospitals involved.
It is to be noted here that even a few tertiary care hospitals in Valley were also earlier issued show-cause notices related to deficiencies in their claims which were detected by the insurance company and duly notified to the concerned, which then lead to the correction of the same.
Simultaneously, they said, in adherence to the established rules and regulations, over time, the empanelment of several hospitals has been revoked as a consequence of the fraudulent practices that were exposed.
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