AI and Big Data Save Rs 630 Crore from Fraud in UP's Ayushman Bharat Scheme
Technology-led checks under the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY) have prevented fraudulent claims worth nearly Rs 630 crore in Uttar Pradesh over the past two years. The National Health Authority used artificial intelligence and big data analytics to achieve this significant saving.
How Technology Prevents Fraud
Sunil Kumar Barnwal, chief executive officer of the National Health Authority, explained the system's effectiveness. "When we plug a fraud, that money doesn't disappear," Barnwal said. "It stays within the system to fund legitimate treatments, strengthen hospitals, and expand access for beneficiaries."
Uttar Pradesh presents both the biggest challenge and greatest opportunity for PMJAY's digital architecture. With the highest number of beneficiaries and claims nationwide, UP serves as a comprehensive stress test for the scheme's fully digital, IT-driven framework.
Every step of the process operates online with minimal manual intervention. This includes beneficiary identification, hospital admission, treatment documentation, claim processing, and final payments.
Transparent and Neutral System Design
The claims processing system follows a blind, first-in-first-out approach that ensures complete neutrality. "Doctors who adjudicate claims don't know which hospital submitted them," Barnwal explained. "This design choice eliminates discretion and bias, allowing PMJAY to function at scale in a large state like UP without leakage."
Transparency and predictability form the foundation of the system's success. Hospitals receive timely payments for genuine claims, while beneficiaries know their entitlements cannot be denied arbitrarily.
The same IT backbone enables Uttar Pradesh to operate within a national health assurance framework without building parallel systems. This reduces administrative costs significantly and enables tighter monitoring of all transactions.
Data-Driven Fraud Detection
Over seven years of operation, PMJAY has generated more than 11 crore treatment records. A substantial portion of this data comes from Uttar Pradesh. This massive dataset now powers AI-driven fraud and anomaly detection systems.
Every new claim undergoes thorough checking against historical patterns. The system flags duplicate procedures, repeat admissions, manipulated reports, and reused diagnostic images for further investigation.
"About thirty percent of system-flagged suspicious claims eventually get confirmed as irregular," Barnwal revealed. "We expect this detection rate to improve as machine learning models gradually replace rule-based checks."
AI Applications Beyond Fraud Prevention
The state has also piloted several AI-based healthcare interventions with promising results:
- Smartphone-based cataract screening tools with reported accuracy exceeding 96%
- AI-based screening for oral cancer showing encouraging early results
- Artificial intelligence applications for breast cancer detection
These tools enable ASHA workers to identify patients earlier and improve healthcare outcomes across communities.
Transformative Impact on Households
The Economic Survey 2024-25 highlights the scheme's growing impact on families. Earlier cancer detection and a sharp reduction in out-of-pocket health expenditure represent significant achievements.
Out-of-pocket spending has dropped dramatically from around 64% to nearly 39% for participating households. "For families in Uttar Pradesh, this protection against catastrophic health costs proves truly transformative," Barnwal emphasized.
Future Focus on Preventive Care
Sustaining these gains requires stronger emphasis on preventive healthcare measures. The transformation of health sub-centres into Ayushman Arogya Mandirs represents a strategic shift in approach.
Backed by digital health records and disease surveillance systems, these centers aim to prevent illness rather than merely pay for treatment. "If India hopes to become a developed nation by 2047, Uttar Pradesh must become a healthy state," Barnwal concluded.
The integration of technology continues to strengthen healthcare delivery while protecting precious resources from fraudulent activities.
