Madhya Pradesh is investigating 71 hospitals over suspected Ayushman Bharat claim irregularities worth approximately ₹12 crore.
The State Health Agency initiated the investigation after an audit of digital records identified suspicious claims submitted by private hospitals under the government healthcare scheme. Preliminary findings include alleged treatment claims in the names of deceased patients and questionable intensive care unit admissions.
Which Hospitals Are Under Investigation?
The investigation covers 71 private hospitals across Madhya Pradesh, including facilities in Bhopal, Indore, Gwalior, Jabalpur, Ujjain, Rewa, Sagar, Satna, Neemuch, Shajapur and Tikamgarh.
These hospitals had submitted online claims seeking government reimbursement for treatment provided under Ayushman Bharat. Discrepancies identified during a review of the records prompted authorities to examine claims worth approximately ₹12 crore.
FCRF Launches CP-FRM to Build India’s Next Generation of Fraud Risk Professionals
What Irregularities Have Been Detected?
One major concern involves treatment and medication expenses allegedly recorded against patients who had already died. Investigators have also identified cases where patients were shown as admitted to intensive care units despite questions about whether such treatment was medically necessary.
Authorities suspect these practices may have been used to obtain higher reimbursements from the government. However, the allegations remain under investigation, and further action will depend on the findings.
How Did the Software Identify Suspicious Claims?
The Transaction Management System (TMS), used under Ayushman Bharat, helped identify the questionable transactions.
The software tracks patient registration, hospital admission, treatment, discharge and final billing. It also generates alerts when submitted claims contain potentially suspicious information. Around four out of every 100 bills may ordinarily be flagged for additional scrutiny. An unusually high number of alerts associated with the 71 hospitals prompted a closer examination of their claims.
What Action Could Hospitals Face?
Madhya Pradesh authorities have previously penalised hospitals for alleged violations of Ayushman Bharat rules.
In earlier action, 25 hospitals in Bhopal were fined a combined ₹2.11 crore, while another 50 hospitals collectively faced penalties of ₹3.13 crore. Additionally, 18 hospitals were blacklisted and the licences of 15 hospitals were suspended.
Officials have indicated that hospitals found responsible in the current investigation could face legal proceedings, including FIRs, and possible closure. The investigation is intended to establish whether public funds allocated for healthcare beneficiaries were improperly claimed.
The suspected irregularities highlight the importance of checking hospital claims against patient records and medical requirements. Automated alerts can identify questionable transactions, but detailed investigations remain necessary to establish wrongdoing and protect public healthcare funds.
Follow for daily updates on cybercrime, corporate fraud, DFIR, hacking, investigations, and digital forensics
