Health Minister Rushikesh Patel on Monday unveiled a comprehensive update to the standard operating procedures (SOP) for the Pradhan Mantri Jan Arogya Yojana – Mukhyamantri Amrutam (PMJAY-MA) scheme. The revised SOP comes amid state-wide reports of irregularities in private and government hospitals.
Under the updated guidelines, private hospitals have been empanelled to extend healthcare access to residents in remote areas. To ensure the efficient implementation of the scheme, district teams will collaborate closely with insurance providers to verify beneficiaries and services.
Addressing a press conference in Gandhinagar, Patel said, “The PMJAY-MA scheme offers a wide range of benefits, including day-care and prescribed treatments for secondary and tertiary diseases. Enhanced guidelines now encompass cardiology, radiology, total knee replacement (TKR), total hip replacement (THR) and neonatal services.”
He asserted that “treatments include care for ear, nose and throat (ENT) conditions, gynaecological issues, psychological disorders, serious injuries and diseases affecting the heart, kidneys, liver, brain and infants. Cancer treatments, organ transplants, knee and hip replacements and cochlear implants are also covered under the scheme”.
“Beneficiaries are entitled to hospital registration, consultation, diagnostic laboratory reports, surgeries, post-surgery follow-ups, medicines, admission charges, patient meals and travel expenses. The government has integrated additional benefits under the ‘Chiranjeevi Yojana’ and ‘Bal Sakha Yojana’ to ensure safe delivery services for economically disadvantaged pregnant women and NICU facilities for newborns in priority areas,” Patel said.
As of December 04, 72,79,797 claims, amounting to Rs 15,562 crore, have been settled under the scheme. “The state and central governments are committed to the welfare of the economically weaker sections. People need not spend a single penny on medical care, as secondary and tertiary treatments are fully covered,” he emphasised.
Anti-Fraud Measures and Audits
To address fraudulent practices, including those highlighted in the Khyati Multispeciality Hospital case, the State Anti-Fraud Unit (SAFU) has been reinforced. A dedicated team comprising government officials and members of the Gujarat Medical Education and Research Society (GMERS) will monitor treatment-related activities and investigate beneficiary complaints.
“The Chief District Health Officer/Medical Officer of Health will conduct monthly audits of at least two hospitals in each district. Third-party audits will be intensified through a tender-based field audit process, examining two to three per cent of cases daily. Desk audits have been expanded, with insurance companies providing additional specialists for oversight,” Patel described.
The National Health Authority (NHA) has been requested to implement triggers to prevent the misuse of treatment packages.
Dhananjay Dwivedi, Principal Secretary, confirmed, “Over 14 hospitals have been suspended and penalised Rs 18 crore in 2024 alone. Doctors and specialists are actively involved in SAFU operations. Pre-authorisation for emergencies like heart attacks is streamlined and planned surgeries are managed under strict scrutiny.”
He added that Gujarat processes over 4,000 pre-authorisation claims daily.
Commissioner of Health, Harshadkumar Patel, stated, “We are committed to keeping the central government updated on these modifications. These measures ensure greater accountability and transparency in delivering medical services.”
According to Health Minister Patel, the PMJAY-MA scheme benefits approximately 97 lakh families, covering 2.65 crore individuals. The scheme is operational across 900 private hospitals and over 1,500 government hospitals in Gujarat.
On being asked about the alleged fraud in hospitals, Minister Patel acknowledged challenges, saying, “There have been complaints regarding the scheme and we have addressed instances where hospitals tried to exploit it. We have suspended over 10 hospitals and penalised several others. These SOPs are designed to curb such malpractices and enhance cardiology and other medical treatments under central guidelines.”
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