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How Uttarakhand-based MP Memorial Hospital lied its way into Pradhan Mantri Jan Arogya Yojana

Maitri Porecha New Delhi | Updated on September 30, 2019 Published on September 28, 2019

A tale of health insurance fraud

A year since free health cover of ₹5 lakh per family was rolled out by the government under the Pradhan Mantri Jan Arogya Yojana (PM-JAY) for the poor, it has cracked down on 97 hospitals for indulging in fraudulent practices.

MP Memorial Hospital is one such hospital; it has since been de-empanelled by the government for allegedly having indulged in malpractices worth over ₹75 lakh under PM-JAY. The Uttarakhand State Health Authority (SHA) came down heavily on MP Memorial Hospital in a scathing order, a copy of which has been accessed by BusinessLine. The hospital has been black-listed and a first information report (FIR) has been filed against it with the police.

Fuljehan, (39), is one of the many beneficiaries of PM-JAY, whose identity was falsely used by the hospital to raise a claim under her name. In March earlier this year, the hospital had organised a health camp in Fuljehan’s mohalla. They encouraged women to come to the hospital by offering discounts on ultrasound tests and priced them at ₹500 a scan.

After the scan was conducted, the doctors asked her to get admitted citing an issue in her scan.

An admitted patient was asked to get up from his bed and Fuljehan was asked to take his place. After she lay down, her photo was taken, and then she was asked to get up. Some tests were recommended after which she was asked to go home. Doctors took a picture of her e-card and put in a fraudulent claim recording that they had admitted her for four days to treat her for enteric fever.

Inflated numbers of dialysis patients

The SHA’s inquiry revealed that claims worth ₹39.24 lakh for dialysis of 1,962 patients were fraudulent. The authority has directed the hospital to return ₹17.94 lakh, relating to 897 cases, that it has already received. Moreover, SHA has said that pending claims worth ₹20.76 lakh relating to 1,062 cases, will not be paid to the hospital.

SHA noted that for 71 days, every day the hospital was taking in more than 10 patients for dialysis procedures on five available machines, which is not only impossible but also very suspicious. Each dialysis requires four hours, after which the machine has to undergo disinfection and rinsing for another four hours; only after this can it be used for the next patient. If this protocol is not followed, patients are at risk of acquiring infections in the blood. On February 7, the hospital said it conducted as many as 14 dialysis procedures on five machines. On May 13, it claimed to have conducted 16 dialysis procedures.

In two cases, the hospital records show that dialysis had been conducted twice around for both patients. Within a span of eight minutes, on April 11, the same patient was shown to have been admitted twice, once at 10:46 and then again at 10:54.

Also, it was observed that the hospital has no nephrologist on its rolls. SHA noted that it is a serious compromise to conduct a dialysis in the absence of a nephrologist and it puts patients’ lives in danger. The hospital claimed that Dr Santosh Srivastava (who is also the owner and shareholder of the hospital) is a post-graduate MD (Medicine). SHA, however, noted that Srivastava is merely an MBBS doctor and that he has a Russian PG degree, which is not accepted by the Government of India.

Inflated number of patients in the ICU

MP Memorial Hospital has an Intensive Care Unit (ICU) with 10 beds. However, it made a fraudulent claim of ₹7.2 lakh for 200 additional patients in the ICU. The hospital had declared bed occupancy ranging from 12 to 20 patients per day, when it had only 10 beds. While a normal bed costs ₹1,800 per day, a high dependency unit (HDU) bed costs ₹2,700 per day, and an ICU bed costs ₹3,600 per day. Patients admitted in normal and HDU beds were shown to be admitted in the ICU. The SHA inquiry revealed that in the course for 42 days, the hospital claimed to have admitted 263 patients in the ICU, more than the number it could possibly accommodate. Later, an audit revealed that the hospital had recently converted a general ward into an ICU in a rush, and that the so-called ICU functioned like a general ward; only the name was changed to ‘ICU 2 General Ward’.

Pre-authorisation taken after discharge

In at least 85 cases, SHA noted that the days of stay of the patients had been inflated to claim bigger amounts and false claims of up to ₹6.5 lakh had been raised. For example, in one case, a patient stayed in the hospital from February 10 to 13, and at the rate of ₹6,000 per day was entitled to ₹18,000, but the hospital claimed ₹24,000. In another case of animal bite, a patient was admitted on October 12 last year and administered one dose of medicine. But the hospital made a claim for five doses. The SHA further noted that in 22 cases, pre-authorisation was taken after the discharge of the patient, and that these claims seemed fraudulent.

Even as the hospital was not approved to conduct urology, paediatric surgery, poly trauma and plastic surgery cases, 29 patients were operated under these procedures. SHA stated that the hospital was only approved to handle medicine, surgery, obstetric, gynaecology and neonatology cases.

Fraud in mother and new-born care

The SHA analysed births at the hospital and found out that of 31 caesarean surgeries, neonatal packages had been availed in 28 cases. In four of these cases, neonatal package was availed twice over in the same name. The SHA observed that in caesareans only 15 per cent cases need neonatal care packages, but in this hospital,’ such packages were availed 90 per cent of the time, which was suspicious. In total, 32 neonatal cases were analysed and none of them required Neonatal Intensive Care Unit admission. SHA has stated that fraudulent claims worth ₹9.99 lakh were made in this case.

Lack of doctors

The SHA has said that there are no round-the-clock MBBS doctors in any of the five specialities of the hospital and that it is a serious compromise with patient health. It was observed that there are no duty doctors in the hospital. Shockingly, six of the seven doctors are not registered by the Uttarakhand Medical Council, it was noted. In what SHA has called a conflict of interest, AK Sirohi, a doctor working in a State government-run Primary Health Centre (PHC) was also shown as working in the hospital.

Also, while five patients died in the hospital, according to the Mortality Audit Committee, SHA, which, ideally, had to be informed within 48 hours, was not informed. Moreover, the hospital had no hospital registration certificate, stated the SHA.

Published on September 28, 2019
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