Why Haryana wants cameras in hospitals before settling insurance claims

On January 7, a senior official of Ayushman Bharat in Haryana wrote to 1,300 public and private hospitals, asking them to install cameras in their intensive care units and provide live footage of the patients admitted.

The directive said that the hospitals’ claims under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana would be processed based on the CCTV feed they provide to the state agency.

The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana is a cashless health insurance scheme for the poor, and senior citizens above 70. Under the scheme, beneficiaries can avail free treatment up to Rs 5 lakh at empanelled hospitals, which are then reimbursed by the government.

The order was meant for all hospitals in the state that have signed up for the Union government’s cashless insurance scheme, Pradhan Mantri Jan Arogya Yojana.

The directive went on to warn hospitals of financial penalties, suspension and administrative action if they failed to comply. If technical issues led to loss of camera feed or if a hospital failed to provide the feed, the state may deduct or reject their claims, the authority said.

The controversial directive provoked a sharp reaction from private hospitals in the state, who refused to implement it, citing patient privacy. The government hospitals, while officially not opposed to it, are yet to implement the order.

The Indian Medical Association has asked the state authority to withdraw the directive. “In an ICU, there are sick and vulnerable patients who need sponging and close monitoring,” Dr Sunila Soni, the president of Indian Medical Association, Haryana, told Scroll. “If we put cameras on them, it is a breach of their privacy.”

After protests from hospitals, the Haryana authority revised the directive to ask for cameras in the corridors leading to ICUs and at entry and exit points.

At the heart of the controversy is the long unresolved issue of hospital bills, insurance claims and allegations of fraud.

Hospitals say the government is purposely delaying payments and deducting amounts, while several state governments accuse hospitals of submitting fraudulent bills.

Over the last two years, private hospitals have taken out large protests in Haryana, Gujarat and Kerala, over delay in payments under the Pradhan Mantri Jan Arogya Yojana.

The CCTV order

In the January 7 letter, the joint CEO of Ayushman Bharat in Haryana argued that the directive was issued “in order to strengthen transparency, accountability, effective monitoring in the implementation of Ayushman Bharat Pradhan Mantri Jan Arogya Yojana and to prevent any misuse of scheme benefits”.

After doctors protested, the authority revised the directive, stating that cameras would only be positioned at entry and exit points of ICUs and high-dependency units and corridors, and would not reveal the identity of patients. They would not be placed in patient rooms, or in bedside and nursing care areas.

“The sole objective of installing these cameras is to monitor and prevent malpractices such as false booking or inflated booking,” the clarification stated.

False booking refers to a hospital submitting bills of a patient’s treatment to support a claim, even when no actual patient has been admitted. In inflated bookings, the hospital shows it is conducting a higher number of procedures than it has performed. “The live feed shall be utilised solely for verification, monitoring, audit and processing of claims,” the directive said.

Hospitals have to store the feed for 30 days and ensure the cameras are functional at all times, the order said. While claims are processed, CCTV surveillance may be used as a “supplementary tool” for audit, claim verification and fraud investigation.

The onus of data safety, maintaining cameras, storing footage, and prevention of tampering lies with the hospitals.

Why hospitals are protesting

Soni, the president of IMA, Haryana, told Scroll that the directive “came like a bolt from the blue”. She pointed out that an ICU includes all kinds of patients – including those not opting for the PMJAY scheme and those paying their own bills. “Even their recording will go to the government if we comply.”

Soni suggested that the government instead carry out manual inspections to ensure no forgery is taking place. “When a hospital signs a contract under Ayushman Bharat, it agrees to surprise inspections. The Ayushman Bharat vigilance team can do manual inspections. But they don’t visit regularly,” she said.

Dr Sunil Arora, who runs Surya Ortho and Trauma Centre in Faridabad, said the directive is not practical. “How do they plan to address privacy concerns?” he asked. “Patients are changed on the bed, or their clothes are partially removed to give an injection. What if a patient refuses being recorded on camera?” Arora said.

He added that in order to comply with the government, hospitals will have to spend on installing CCTVs.

Hospital malpractice?

In March last year, the Union health ministry informed the Rajya Sabha that since the inception of PMJAY, 3.56 lakh fraudulent claims have been rejected, totalling Rs 643 crore. At least 549 hospitals have been suspended for fraudulent claims across India.

An official from the Union health ministry said they are strengthening state anti-fraud units “to look into all kinds of malpractices”. “Such instances have reduced, more steps are being taken,” the official added.

Government officials in Haryana told Scroll that the directive was aimed to curb malpractice by hospitals.

Dr Sandeep Singh, the nodal officer of Ayushman Bharat for Sirsa district in Haryana, said overcharging patients is a common malpractice. The PMJAY scheme ensures cashless service up to Rs 5 lakh.

During inspections, Singh said he often found hospitals submitted bills for reimbursement to the state authority – even after they had charged patients. “If cameras are placed and we have access to the feed, hospitals will become more vigilant,” Singh said.

In Jhajjar, nodal officer Dr Sunita Tawar said she had asked a hospital to refund a patient as they had made her pay up. “The patient was charged even when the treatment was supposed to be free,” she said.

The nodal officer for Mewat district, Dr Vishal Singh, also flagged instances of fraud. Three months ago, he said he found that a patient supposed to be undergoing treatment at a hospital was not in the hospital at all. “We reject claims in such cases,” he said. “But constant physical monitoring by inspecting each patient is not possible. And there has to be a way to ensure hospitals reduce malpractices. The idea of CCTV may help to some extent.”

‘A lot of mistrust’

But several doctors argue that the problem was mistrust.

“There are some who indulge in inflated bills and fraud. But all hospitals are bearing the brunt of it,” said Dr Ramesh Chaudhary, who led a protest over unpaid dues in Gujarat against the government.

Chaudhary said the scrutiny of PMJAY claims are often rejected over minor errors “even if there is no intentional fraud.” “The government thinks each hospital is cheating them to get a higher payout,” he added. “There is a lot of mistrust.”

Hospital authorities also complain of an increasing compliance burden and unpaid bills.

Dr Yogesh Jindal, general secretary of IMA in Haryana, said till last September Rs 450 crore dues were yet to be paid to empanelled hospitals in the state. “After our protest, the government sanctioned Rs 325 crore,” he said.

Soni, the IMA state president, said so far only Rs 7 crore have been disbursed. Scroll was unable to verify this claim with the Haryana state authority.

Dr Jindal pointed out that the government is supposed to pay 18% annual interest if payments are delayed beyond a month. “But they are not paying the interest. Instead, the list of compliances is increasing each day,” he said. “We have to upload test reports on a daily basis for patients. There is too much to document. PMJAY is becoming an unfeasible scheme for the private sector.”