Evaluating the Efficacy and Fraud Detection Mechanisms of AB-PMJAY TMS 2.0 A Mixed-Methods Study Integrating Quantitative and Qualitative Insights

Author : Sweety Patel

Abstract :In the present setting, fraudulent claims under AB-PMJAY entail imminent threats to the program's financial viability and equitable distribution of healthcare services. Hence, there is an urgent need to implement a strong framework for detection and prevention. This study looks at the prevalence and pattern of fraudulent claims under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PMJAY) in addition to assessing the efficacy of mechanisms to detect fraud. Mixed methods were employed for data collection with structured questionnaires involving 390 respondents of varying hospital types across Delhi NCR and were supplemented by secondary data drawn from government reports and academic literature. The quantitative analysis applied, including ANOVA, found that the frequency of fraudulent claims differed substantially among hospitals of varying strengths, with larger hospitals demonstrating well-organized fraud as compared to smaller and medium-sized establishments. Qualitative findings indicated that while AI-based audit and pre-authorization checks have the potential to reduce fraud, challenges remain, including false positives, difficulty in accepting a new paradigm of working by stakeholders, and infrastructure limitations. The findings underscore the critical need for comprehensive and adaptive fraud prevention strategies to ensure the financial sustainability and equitable delivery of healthcare services under AB-PMJAY.

Keywords :AB-PMJAY, Blockchain, Claims, Empanelled Hospitals, Fraud, Healthcare.

Conference Name :International Conference on Health Care Reform, Health Economics and Health Policy (ICHCRHEHP-25)

Conference Place Chandigarh, India

Conference Date 27th Sep 2025