Gujarat has introduced a new Standard Operating Procedure (SOP) for the Pradhan Mantri Jan Arogya Yojana (PMJAY) 40 days after the Khyati Hospital scam rocked the nation.
The scam, which came to light on 12 November, revealed that Ahmedabad’s Khyati Hospital falsely conducted an estimated 700 operations to claim over ₹27 crore in PMJAY reimbursements.
The Gujarat government announced the new SOP to curb fraudulent practices in PMJAY reimbursements. It is expected that the central government may adopt similar measures in due course to ensure transparency and prevent misuse under the scheme.
Under the revised SOP, hospitals are now required to record video evidence when informing patients and their relatives about certain treatments. These treatments include angiography, angioplasty, bypass surgery, amputations, and ectomy procedures.
The guidelines also apply to spinal surgeries, brain surgeries, cancer treatments, organ donation, transplantation, and retrieval surgeries. Hospitals must obtain signed consent from patients or their relatives after providing complete information about the procedures.
Upon a patient’s discharge, hospitals must provide not only a discharge summary but also all relevant laboratory, radiology, and diagnostic reports. This will ensure that patients have access to their medical records for future reference.
Additionally, all hospitals in the state must adhere to the Government of India’s infection control and prevention guidelines.
To strengthen oversight, the State Anti-Fraud Unit (SAFU) has been bolstered to monitor treatments provided by hospitals more closely.
A dedicated team, comprising members from the government and GMERS medical colleges, will be established in each district. These teams, guided by SAFU, will audit empanelled hospitals and address complaints from PMJAY beneficiaries.
Further, Chief District Health Officers (CDHO) and Medical Officers of Health (MOH) must visit and audit at least two hospitals each month. Independent third-party field audit teams, appointed through a tendering process, will conduct daily field audits for 2-3% of cases.
Insurance companies have also been instructed to recruit additional specialists and super-specialists to strengthen their desk and field audits. Hospitals will be required to generate alerts as advised by the National Health Authority (NHA) to identify potential misuse of medical packages.
Specific guidelines have been issued for hospitals offering cardiology services. To qualify as a cardiology cluster, a hospital must employ a full-time cardiologist, cardio-thoracic surgeon, cardiac anaesthetist, and physiotherapist.
Centres providing cardiologist services are allowed to perform angioplasty only in cases of severe emergencies.
For cancer treatments, a patient’s care plan must be determined by a tumour board comprising a medical oncologist, surgical oncologist, and radiation oncologist. The tumour board must upload a certificate detailing the patient’s treatment plan.
Additionally, for image-guided radiation therapy, hospitals must mandatorily use CBCT imaging in kilowatt settings. Brachytherapy treatments can only be provided by hospitals with in-house facilities, as external tie-ups will no longer be permissible.
The SOP, which was unveiled by Gujarat Health Minister Rushikesh Patel, includes 18 key measures. These comprise six for cardiology, four for cancer treatment, six for neonatal care, one for orthoplasty, and one pertaining to the Clinical Establishment Act.
The Gujarat government’s proactive measures aim to restore credibility to PMJAY and ensure that patients receive the intended benefits without exploitation.
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