Gujarat’s Health Minister Rushikesh Patel on Monday laid out the new standard operating procedure (SOP) for the PMJAY-MA scheme, implemented in all the districts of the state to provide health assistance.

Under this, private hospitals are empanelled to provide access to healthcare for the people of remote areas. The district teams and insurance providers of the scheme will work together for verification.

The benefits of the PMJAY-MA include day care and prescribed treatment for secondary and tertiary diseases.

New guidelines have been made for cardiology, radiology, TKR/THR (Total Knee Replacement/Total Hip Replacement) and neonatal services.

These include ear, nose and throat diseases (ENT), gynaecological, psychological, heart, kidney, and brain diseases; serious injuries, serious diseases related to infants, cancer, knee and hip replacement, heart, kidney, liver, uterus transplantation as well as a cochlear implant.

The beneficiary is entitled to the benefits of hospital registration, consultation, laboratory reports for diagnosis, surgery, post-surgery follow-up services, medicines, admission charges, food for the patient, travel expenses, etc.

The Gujarat government has also included the benefits of 'Chiranjeevi Yojana – Mukhya Mantri Chiranjeevi Swasthya Bima Yojana' and 'Bal Sakha Yojana' in the 'PMJAY-MA' with the aim of providing safe delivery services to pregnant women from economically backward classes by involving experts from the private sector and providing NICU facilities for newborns in high priority talukas of the state.

A total of 72,79,797 claims have been paid under the PMJAY-MA scheme in the state till December 4, 2024, amounting to ₹15,562 crore, informed the minister.

State Anti-Fraud Unit (SAFU)

To curb the exploitation of the scheme like the recent Khyati hospital row, the State Anti-Fraud Unit (SAFU) has been strengthened to monitor treatment-related activities in all hospitals of the state.

Under that, a separate team has been formed from the government and GMERS (Gujarat Medical Education and Research Society) to prevent fraud by private hospitals.

The SAFU team will visit hospitals in their districts and verify the treatment-related activities and if there is any complaint from the beneficiary, they will bring it to the notice of the government.

Chief District Health Officer/Medical Officer of Health will conduct audit visits to at least two hospitals on a monthly basis.

As part of the third-party audit, field audit will be planned through the tender process. In which the field audit team will conduct field audit of two to three per cent of the cases on a daily basis.

Desk audit and field audit have also been intensified by providing more specialists and super specialists by the insurance companies.

National Health Authority (NHA) has been requested to generate the necessary triggers to prevent possible misuse of treatment packages by hospitals.

PMJAY in Gujarat

According to Health Minister Patel, approximately 97 lakh families or 2.65 crore beneficiaries are getting regular treatment at approximately 900 private and more than 1,500 government hospitals under PMJAY.

Over 14 hospitals have been suspended, de-empanelled, and penalised for malpractices in 2024. In some cases, doctors have been removed from the scheme and necessary action has been taken by the medical council.

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