National Health Authority (NHA) has uncovered over 4.63 lakh suspicious claims under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PM-JAY) from September 2023 to March 2025, as revealed in its 2024-25 annual report released during a two-day national review meeting in Bhopal, Madhya Pradesh. The world’s largest publicly funded health insurance scheme also flagged 1.33 lakh claims worth Rs 272 crore as outright fraudulent, blocking payments to safeguard public funds. The NHA has shared these suspicious claims with states for deeper investigation, highlighting the urgent need to protect the scheme’s integrity as it battles systemic abuses in all states except West Bengal, which does not implement AB-PM-JAY.

The NHA’s National Anti-Fraud Unit (NAFU) has been instrumental, conducting approximately 120 Joint Field Medical Audits and over 2,283 Desk Medical Audits across states and Union Territories, with suspicious entities referred to state authorities for further scrutiny. The report stresses that “institutionalizing an anti-fraud framework is key to preserving trust,” outlining plans for predictive analytics, real-time monitoring, and automated checks to proactively curb fraud.

This builds on existing AI-driven tools that have already identified 410,000 suspicious claims, confirming 1.49 lakh as fraudulent, worth Rs 232.39 crore. In regions like Punjab, Haryana, and Himachal Pradesh, Rs 74.5 crore in inadmissible claims from 2.7 lakh cases—13% of national fraud—stem from issues like inflated billing and ghost treatments by private hospitals.

Launched in 2018, AB-PM-JAY provides up to Rs 5 lakh per family annually for secondary and tertiary care hospitalizations, covering 15.14 crore eligible families (over 80 crore individuals) from the bottom 40% of the population, plus 8.57 crore families under state schemes as of March 31, 2025. The program has facilitated 9.19 crore hospital admissions worth Rs 1.29 lakh crore, with private hospitals handling 52% of cases but claiming 66% of funds, compared to 34% for public facilities. Recent expansions, like the October 2024 Ayushman Vay Vandana Cards for seniors over 70, have added 20.4 lakh beneficiaries from 4.5 crore families, amplifying the scheme’s reach amid these fraud challenges.

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At the Bhopal meeting, NHA CEO Dr. Sunil Kumar Barnwal praised AB-PM-JAY’s “four strong pillars” for benefiting over 45 crore people, while emphasizing zero tolerance for malpractices. Over 3.56 lakh fraudulent claims worth Rs 643 crore have been rejected, leading to the de-empanelment of 1,114 hospitals, with FIRs filed in cases like unnecessary surgeries in Gujarat.

Advanced tools, including facial recognition flagging 2,790 suspicious claims (119 confirmed fraudulent at Rs 18 lakh), and a three-tier grievance system resolving over 18,000 complaints, are fortifying the scheme. As India advances toward universal health coverage, these efforts not only recover funds but also bolster public trust in a critical lifeline for millions.

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