NHA picks SAS for detection of fraud, waste and abuse in PM-JAY

L N Revathy | | Updated on: Jul 26, 2020

SAS will provide solutions, technology and professional consulting services as well

The National Health Authority (NHA) has identified SAS — a global leader in healthcare fraud management and detection — for detecting and preventing fraud, waste and abuse in Pradhan Mantri Jan Arogya Yojana (PM-JAY).

SAS was among five companies shortlisted by NHA for doing a pilot for six months and was assigned the project after an intense evaluation.

Noshin Kagalwalla, Managing Director and Vice-President, SAS India, told BusinessLine that the project has been assigned for three years with scope to extend it beyond this period. “We will provide an entire suite of SAS solutions, technology and professional consulting services as well.”

“NHA has deployed operational systems to support the scheme and shared all the data fed into the system from hospital and beneficiary information, to treatment and procedural information.”

Sharing insights, Kagalwalla said PM-JAY as part of Ayushman Bharat is the world’s largest government-supported health insurance scheme providing health cover up to ₹5 lakh per family per year, primarily covering secondary and tertiary-care hospitalisation.

The scheme supports over 10.74 crore poor and vulnerable families (approximately 50 crore beneficiaries) across India. So far, nearly one crore treatments worth more than ₹12,882 crore have been provided across 19,000 hospitals in 32 States and Union Territories.

NHA started looking for support in terms of framework to detect and prevent fraud and simultaneously cater to the health requirements of this vulnerable section of society. It seemed a huge challenge for NHA as the claims volume processed on a single day was huge which. in turn, required monitoring of multiple entities such as hospitals, beneficiaries and treatment, deployment of tech tools such as artificial intelligence and machine learning, identifying collusion between the entities, and so on, to reduce frauds and false claims.

Kagalwalla did not have details of the claims made since end-March or the frauds volume. Citing a report, he said, “frauds estimated at around ₹71,500 crore occurred in 2018-19. And on the insurance side, and from the healthcare standpoint, it is maintained that around 15 per cent of claims that are under process are estimated to be fraudulent in nature.”

Published on July 26, 2020

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