Improving Fraud Detection under AB-PMJAY: Transitioning from TMS 1.0 to TMS 2.0
Author : Sweety Patel
Abstract :The research examines the efficacy of the Fraud detection system during the transition from TMS 1.0 to TMS 2.0 within ABPMJAY. The Transaction Management System serves as a platform via which an empanelled hospital submits a mediclaim under ABPMJAY, and the Third Party Administrator validates the claim. The incidence of fraud has escalated in TMS 1.0 recently. The Government has transitioned to TMS 2.0, which has enhanced features and capabilities for detecting fraudulent claims. This study seeks to assess the feedback regarding the transition from TMS 1.0 to TMS 2.0, identify the significant correlation between the TMS 2.0 fraud detection system and the actual fraud status of claims, evaluate the fraud detection mechanisms and regulatory measures, and offer policy recommendations for enhancing prevention systems. This mixed-method approach utilizes both quantitative and qualitative data collection approaches. Primary data were obtained from staff of accredited hospitals in Gujarat, while secondary data were sourced from government publications and literature reviews. This study used stratified random sampling to target 336 respondents who have utilized the TMS 2.0 portal of ABPMAJAY. Data analysis was conducted using SPSS and Excel, utilizing frequency distribution and the Chi-Square Test to evaluate the hypothesis. The results indicate a substantial correlation between fraud claim detection and the actual fraud status. The paper emphasises an enhanced method employed in TMS 2.0 to terminate bogus claims
Keywords :Transaction Management System, Chi-Square Test, Hospital claims, Fraud prevention
Conference Name :International Conference on Health Care Reform, Health Economics and Health Policy (ICHCRHEHP-25)
Conference Place Chennai India
Conference Date 26th Apr 2025