In at least 697 cases of irregularities in the government-run cashless health insurance scheme, Ayushman Bharat, in Uttarakhand, 11 hospitals are in the process of being slapped with a penalty of over Rs 1.17 crore.

Uttarakhand's Atal Ayushman Uttarakhand Yojana (AAUY) Scheme, run under the aegis of Ayushman Bharat, has been riddled with irregularities.

After the Union Health Minister Harsh Vardhan sought to know the action taken by National Health Authority (NHA) to correct the irregularities, the latter submitted a detailed report to the Minister’s office on Tuesday. BusinessLine has accessed a copy of the report.

In Uttarakhand it is mandatory for a patient to get a ‘referral slip,’ from a government-run primary health centre (PHC) or a hospital before seeking admission in a private hospital. “A nexus between government and private doctors was taking advantage of this process. We received complaints from certain beneficiaries, who said that there was a delay in issuance of referral slips, and that the errant doctors may have demanded pecuniary benefits for issuing referrals under the AAUY,” a NHA official said.

The report states that Astha Hospital and Jansewa Hospital in Udham Singh Nagar and Priya Hospital in Haridwar have been de-empanelled from the scheme and a fine of Rs 8.4 lakh has been slapped. While a first information report has already been lodged against Astha Hospital, another against Priya Hospital is in the process of being lodged.

Nine other hospitals - five in Udham Singh Nagar, two in Haridwar, and one each in Nainital and Dehradun - have been issued show cause notices to explain their conduct in 601 alleged cases of fraud. They have been recommended for de-empanelment and a total penalty of close to Rs 97 lakh has been calculated, to be levied. “As these nine hospitals are still in the process of investigation, FIRs would be filed only after the final orders are issued,” said the NHA official.

For example, Arogyam Hospital in Haridwar is being investigated for at least 152 cases of irregularities and may end up paying over Rs 29 lakh in fine, if final orders are issued by the government. Nainital-based Brijesh Hospital is being investigated in 85 cases and Dehradun-based Vinod Ortho Clinic in 61 cases, in which they may end up paying a fine of over Rs 15 lakh each. In the case of Dehradun-based Sri Mahant Indresh Hospital in Dehradun, orders for recovery of Rs 11.82 lakh have been issued.

The report further stated that on May 30, the services of three government hospital doctors - Rajiv Gupta and Navpreet Kaur, working at LD Bhatt Hospital in Udhamsingh Nagar, and George Samual, working at the additional PHC in Rayasi at Haridwar - were terminated by the state Director-General (DG, Medical and Health) for their involvement in irregularities.

For example, the government-run PHC at Kelakhera in Udham Singh Nagar district was stated to be hand-in-glove with private-run Jan Sewa Hospital in Kashipur, which is a private empanelled hospital under AAUY, for alleged irregularities in issuance of referral slips. “On June 22, the State Health Authority (SHA), Uttarakhand slapped a fine of Rs 2,70,000 on Jan Sewa Hospital,” the report states.

The report also states, “Seventeen ‘referral slips’ were issued by the PHC, Kelakhera to Aastha Hospital in an illegal manner. The DG and Chief Medical Officer (CMO) of Udham Singh Nagar were also told to take action against Anurag Rawat, a pharmacist at the PHC.”

Subsequently, an FIR was lodged on May 18 under Sections 420, 467, 468 and 471 of the Indian Penal Code against Rajeev Gupta, the owner of Aastha Hospital, and Anurag Rawat, pharmacist at Kelakhera PHC in Kashipur police station. “While the FIR was under investigation, both the accused approached the Nainital High Court to seek a stay,” the report said.

Another example is that of Ali Nursing Home in Kashipur which is being investigated for various irregularities, including issuance of 12 illegal ‘referrals’ by the PHC at Kelakhera.

“After due examination, a final decision will be taken by SHA on cancellation of “empanelment” of the hospital under AAUY, as well as for lodging the FIR,” the report stated.

“There is a continuous audit of claims that are raised by the private hospitals and immediate action is whenever irregularities are detected or complaints are received,” the report stated.

“Various State Health Agencies (SHA) have constituted a “State Anti Fraud Unit (SAFU) to watch, detect and take action against any kind of fraud, irregularity or illegality in claims by the hospital and to check any service deficiency. The SAFU reports to the Chief Executive Officer (CEO) of SHA and to the Executive Committee of AAUY Society,” said another NHA official.