After AI detects RGHS fraud, 3 docs suspended, changes made

Jaipur: Artificial intelligence (AI) technology deployed to detect anomalies in Rajasthan Govt Health Scheme (RGHS) helped identify suspicious patterns in cashless medicine billing, leading to suspension of three govt doctors. On April 24, the govt issued new directives to combat fraudulent activities in the RGHS system. Changes were made in the system of processing bills by pharma stores for reimbursement against cashless medicines provided to beneficiaries.
An RGHS official said Wednesday, "Apart from AI technology, the RGHS team is also taking other measures to prevent any sort of misuse of the scheme by doctors and pharma stores."
In the case of the three suspended doctors, state govt used AI technology to analyse claims made by empanelled chemist stores. "Using AI for scrutiny of OPD pharma bills under RGHS revealed that multiple pharma bills were generated from one OPD prescription," mentioned the new guidelines issued on April 24.
An advisory issued by RGHS said, "All private chemists and confed stores are warned that in such cases, the pharma stores will be responsible, and they may face penalty, suspension, and de-empanelment from the scheme."
In the advisory, the project director officer (RGHS) advised chemists and confed stores to prepare pharma bills against the same name of the beneficiary (patient) as mentioned in the OPD prescription. The bills should have details of the pharma store, the owner's address and mobile number.
To prevent misuse of card details of a beneficiary, the RGHS project director office made it compulsory that medicines will be provided to the beneficiary only when the TID is generated from the patient's SSO-ID. The patient will provide the OTP generated to the pharma store for getting medicines and bills.
Pharma stores have been asked to check the OPD prescription to see if medicines prescribed are normally those as prescribed by super specialist doctors.