Medical Audits in India

India drew on its participation in the JLN’s Medical Audits Collaborative and adaptation of the Medical Audit Toolkit to implement a medical audit system that could be decentralized and scaled by India’s states to review claims, identify fraud, and ensure the quality of health services being provided to patients.

This case study profiles the use of the Toolkit to Develop and Strengthen Medical Audit Systems in India. In 2018, with the launch of the Ayushman Bharath Pradhan Mantri Jan Arogya Yojana (PM-JAY) health insurance scheme, India began providing financial protection to more than 108 million poor and deprived rural families, as well as approximately 500 million urban workers.The scheme is cashless and paperless at all public hospitals and empanelled private hospitals and beneficiaries of PM-JAY are not required to pay any charges for hospitalization expenses. Strong anti-fraud efforts are important not only from the perspective of reducing the adverse impact on the scheme’s finances and for safeguarding beneficiary health, but also to mitigate any reputational risks faced by the SHA, states, and the scheme as a result of fraud.