**Executive Summary**
This document is the response to a starred question in Lok Sabha regarding irregularities in the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) scheme in Andhra Pradesh. The Minister of Health and Family Welfare provides details on the actions taken against hospitals found violating the scheme, including de-empanelment, suspension, and penalties levied. The information is related to a question scheduled to be answered on February 13th, 2026.
**Key Points / Main Content**
* **General Scheme Governance:**
* AB-PMJAY operates with a zero-tolerance approach towards fraud.
* **Fraud Detection and Prevention:**
* The National Anti-Fraud Unit (NAFU) employs AI/ML-based automated triggers to identify suspicious claim patterns such as duplicate entries, inflated procedures, and misuse of patient identity.
* NAFU conducts regular capacity-building workshops and field-level training sessions.
* **Coordination and Action Against Fraud:**
* NAFU collaborates closely with State Anti-Fraud Units (SAFU) to investigate and take action against fraud cases.
* Suspicious cases identified by automated triggers are routed to State Health Authorities for adjudication.
* Actions against fraudulent entities include suspension, issuance of show cause notices, warning letters, de-empanelment of hospitals, levying penalties, and lodging of FIRs.
* **Specific Actions in Andhra Pradesh:**
* 3 hospitals have been de-empanelled.
* 59 hospitals have been suspended.
* Penalties amounting to Rs. 39.23 crore have been levied on 360 hospitals over the last five years (FY 2020-21 to FY 2024-25).
* District-wise details of the actions taken are provided in an annexure.
**Impact Analysis**
**Stakeholder: Ministry of Health and Family Welfare**
* **Impact:** Required to answer questions in the Lok Sabha regarding the AB-PMJAY scheme and demonstrate oversight and action against irregularities.
* **Action Required:** Continue monitoring the scheme for fraud, coordinating with NAFU and SAFU, and taking appropriate action against fraudulent entities.
**Stakeholder: National Anti-Fraud Unit (NAFU)**
* **Impact:** Responsible for detecting and preventing fraud within the AB-PMJAY scheme.
* **Action Required:** Continue using AI/ML-based automated triggers, coordinating with SAFUs, and conducting capacity-building workshops.
**Stakeholder: State Anti-Fraud Units (SAFU)**
* **Impact:** Responsible for investigating cases of fraud flagged under the AB-PMJAY scheme and taking action against fraudulent entities at the state level.
* **Action Required:** Collaborate with NAFU, investigate suspicious cases, and adjudicate cases based on the available evidence.
**Stakeholder: Hospitals in Andhra Pradesh**
* **Impact:** Subject to scrutiny and potential penalties (including de-empanelment and suspension) for violations of AB-PMJAY guidelines.
* **Action Required:** Adhere to AB-PMJAY guidelines, ensure accurate billing practices, and cooperate with investigations by NAFU and SAFU.
**Stakeholder: Beneficiaries of AB-PMJAY**
* **Impact:** Affected by fraudulent activities within the scheme, which can compromise the availability and quality of healthcare services.
* **Action Required:** Be aware of potential fraudulent activities and report any suspicious behavior to the relevant authorities.
Key Entities Referenced
Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY): National health insurance scheme addressing irregularities.
National Anti-Fraud Unit (NAFU): Unit employing methods to detect and prevent fraudulent activities under AB-PMJAY.
State Anti-Fraud Units (SAFU): State-level units coordinating with NAFU for investigation and action against fraud.
Andhra Pradesh: Indian state where hospitals are investigated for irregularities under the AB-PMJAY scheme.
Ministry of Health and Family Welfare: The Union ministry responsible for the administration of the AB-PMJAY scheme.
GOVERNMENT OF INDIA
MINISTRY OFHEALTH AND FAMILYWELFARE
DEPARTMENT OF HEALTH AND FAMILYWELFARE
LOK SABHA
STARRED QUESTION NO. *214
TO BE ANSWERED ON THE 13THFEBRUARY, 2026
IRREGULARITIES IN AB-PMJAY
*214. SHRI LAVU SRI KRISHNA DEVARAYALU:
Will the MINISTER OF HEALTH AND FAMILY WELFARE be pleased to
state:
(a) whether the Government has received cases/complaints of irregularities or violations
done by hospitals in Andhra Pradesh under the Ayushman Bharat Pradhan Mantri Jan
Arogya Yojana (PM-JAY) scheme;
(b) if so, the details thereof alongwith the nature of such violations;
(c) the details of actions taken against such hospitals in the said State, specifically the
total number of hospitals de-empanelled, suspended or penalised along with the amount
of penalty levied, during the last five years, district-wise;
(d) the details of the specific methods and technologies employed by the National
Anti-Fraud Unit (NAFU) to detect and prevent fraudulent activities under the scheme;
and
(e) the details of the coordination mechanism adopted by NAFU with the State
Anti-Fraud Units (SAFU) in terms of data sharing, investigation protocols and real-time
monitoring to ensure timely identification and action against fraudulent entities?
ANSWER
THE MINISTER OFHEALTH AND FAMILYWELFARE
(SHRI JAGAT PRAKASH NADDA)
(a) to (e) AStatement is laid on the Table of the House.STATEMENT REFERRED TO IN REPLYTO LOK SABHA
STARRED QUESTION NO. 214 * FOR 13TH FEBRUARY, 2026
(a) to (e) Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is
governed on a zero-tolerance approach towards fraud. National Anti-Fraud Unit (NAFU)
uses AI/ML-based automated triggers to flag unusual claim patterns such as duplicate
entries, inflated procedures, or misuse of patient identity, etc. Regular capacity-building
workshops and field-level training sessions are conducted to strengthen the overall
anti-fraud framework of AB-PMJAY.
NAFU works in close coordination with the State Anti-Fraud Units (SAFU) to investigate
and take action against cases of fraud. Cases flagged as suspicious by the automated
triggers are routed to the respective State Health Authorities for adjudication. Appropriate
actions including suspension, issuance of show cause notices, warning letter,
de-empanelment of hospitals, levying penalty lodging of FIRs are taken against
fraudulent entities.
In Andhra Pradesh, 3 hospitals have been de-empanelled, 59 hospitals suspended and 360
hospitals have been levied penalty amounting to Rs. 39.23 crore during the last five years
forvariousviolations.Thedistrict-wisedetailsofsuchactiontakenareatAnnexure.Annexure
District-wise detail of action taken against hospitals in the State of Andhra Pradesh
during the last five years (FY 2020-21 to FY2024-25)
District Total numberof Total amountof Numberof Numberof
hospitalson penaltylevied hospitals hospitals
whichpenalty (Rupeesincrore) suspended de-empanelled
hasbeenlevied
ANAKAPALLI 2 0.02 - -
ANANTHAPURAMU 22 1.74 6 -
ANNAMAYA 6 0.04 - -
CHITTOOR 6 0.21 - -
DR. BR AMBEDKAR
8 0.01 - -
KONASEEMA
EASTGODAVARI 17 0.31 14 -
ELURU 3 0.27 1 -
GUNTUR 30 11.90 4 -
KAKINADA 14 0.37 - -
KRISHNA 1 0.01 1 -
KURNOOL 27 6.58 2 -
NANDYALA 3 0.19 1 -
NTR 22 0.40 - -
PALNADU 23 0.76 1 1
PRAKASAM 13 0.12 1 -
SPSRNELLORE 23 1.14 1 -
SRISATHYASAI 6 0.68 - 1
SRIKAKULAM 8 0.16 - -
TIRUPATI 33 0.95 1 1
VISAKHAPATNAM 52 11.39 4 -
VIZIANAGARAM 2 0.07 - -
WESTGODAVARI 15 0.15 2 -
YSRKADAPA 24 1.78 20 -
*****