National Health Authority (NHA), the apex government body implementing India’s flagship public health insurance scheme Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) has chosen SAS a global leader in healthcare fraud management and detection — for detecting and preventing fraud, waste and abuse in Pradhan Mantri Jan Arogya Yojana (PM-JAY).

SAS will enable data analytics for NHA’s National Anti-Fraud Unit (NAFU) and it will help to monitor fraud and abuse arising anywhere in the implementation structure of the scheme.

Through the Fraud Analytics Control and Tracking System (FACTS) of NHA, SAS will also support the prevention and detection of fraud through a health-care specific fraud and abuse data model that consolidates data from internal and external sources including claims systems, third parties as well as unstructured text. Thus, contributing to the NHA’s overall objective of detecting and minimizing health care fraud using advanced analytics.

Noshin Kagalwalla, VP & Managing Director – SAS India said, “Providing healthcare access to poor and vulnerable families across India is a complex process. But data backed with analytics, can ascertain a holistic view. NHA’s FACTS project is aimed at detecting and minimizing health care fraud using advanced analytics. With SAS software, we have provided a framework of support to not just detect & prevent fraudulent claims but also provide a broader view of patients being served under the PM-JAY scheme”

Also read: Survey claims:1.5 lakh Ayushman Bharat Health & Wellness Centres to be set up by 2022

SAS will provide an end-to-end framework for ensuring claim processing with specific components for fraud detection, alert management and case handling for NHA.

Talking about the partnership, Dr Indu Bhushan, Chief Executive Officer, National Health Authority (NHA) said, “After a six month-long proof of concept exercise where five top global analytics firms participated, we are pleased to select and have SAS support us in analyzing one of the largest disparate data sets pertaining to health care administration through a central platform. We will employ advanced data analytics to all the claims we are processing as well as administering to identify anomalies and detect and prevent fraud and abuse from occurring across the board. We are confident that with this, Ayushman Bharat PM-JAY will further strengthen its service delivery to more than 50 crore poorest citizens and empower them with quality secondary and tertiary healthcare.”

SAS’ fraud analytics engine enabled for NHA’s FACTS uses multiple techniques such as automated business rules, outlier analysis, predictive modeling, text mining, database searches, exception reporting as well as network link analysis to uncover the likelihood of fraud for a health insurance scheme that benefits over 10.74 crore families living in poverty. Furthermore, the analytics engine is enabled to use advanced analytics with embedded artificial intelligence (AI) and machine learning algorithms to prevent and detect fraud across India for the ambitious scheme.

Ayushman Bharat PM-JAY is the world’s largest government-supported health assurance scheme that provides a health cover of Rs. 5 lakhs per family per year to cover secondary and tertiary care hospitalization to over 10.74 crore poor and vulnerable families across India. So far, nearly 95 lakh treatments worth more than Rs. 12,882 crore have been provided across 19,000 hospitals in 32 States and Union Territories.

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