CAG Audit Uncovers Critical Implementation Gaps in Bihar's Ayushman Bharat Scheme
The Comptroller and Auditor General (CAG) has issued a damning report highlighting significant deficiencies in the execution of the Ayushman Bharat health insurance scheme in Bihar. The audit reveals that weak awareness campaigns and procedural bottlenecks have severely restricted the scheme's reach, resulting in eligible patients being systematically denied crucial treatment benefits.
Severe Awareness and Verification Shortfalls
The CAG audit found that expenditure on information, education, and communication activities was substantially below required levels, directly contributing to poor beneficiary awareness and verification rates. Bihar's revised target, established in January 2022, aimed to cover 6.18 crore beneficiaries. However, as of March 2024, only 2.56 crore beneficiaries—approximately 41% of the target—had been successfully verified, leaving millions potentially excluded from healthcare coverage.
Pre-authorization Process Breakdown
The report identified critical flaws in the pre-authorization process affecting both beneficiaries and healthcare providers. Among 14,015 rejected pre-authorizations, a staggering 8,371 cases—representing about 60% of rejections—were turned down by Pre-authorization Panel Doctors. These rejections, amounting to Rs 12.20 crore in denied treatment value, were primarily attributed to:
- Delays in initiating pre-authorization requests
- Incorrect selection of treatment packages
- Non-compliance with queries raised by scheme coordinators
Furthermore, the audit discovered that PMAM kiosks, designed to assist beneficiaries with formalities, were not operating round-the-clock in 54 sampled public and private hospitals, creating additional access barriers.
Hospital Onboarding and Activation Challenges
The CAG report documented significant delays in hospital empanelment, with 383 private hospitals approved after procedural hold-ups. Among these, 159 hospitals faced delays of 200 days or more before becoming operational under the scheme. As of September 2024, Bihar had 1,005 hospitals empanelled under Ayushman Bharat, but 226 hospitals—representing 22% of the total—were shown as inactive for not initiating any pre-authorizations for beneficiaries during the previous three months.
Claim Processing Deficiencies
The audit revealed substantial deficiencies in claim processing mechanisms. Payments could not be processed in 34,193 cases due to claim rejections by Claim Panel Doctors. Primary reasons for these rejections included:
- Delayed claim initiation
- Wrong package selection by hospitals
- Failure to upload mandatory documents
- Non-submission of replies to queries
In a particularly concerning compliance lapse, the CAG found that out of 8.10 lakh claims processed, 1.73 lakh claims worth Rs 199 crore were handled without mandatory Aadhaar-based biometric authentication at the time of patient admission and discharge, raising serious questions about verification protocols and potential misuse.
The comprehensive audit underscores systemic implementation failures that have compromised the effectiveness of Ayushman Bharat in Bihar, potentially depriving vulnerable populations of essential healthcare services despite the scheme's ambitious objectives.
