Navigating the Ayushman Bharat Crisis: Challenges and Resolutions for Healthcare Providers

The Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), designed to provide a health cover of up to Rs 5 lakh per family annually for secondary and tertiary care, is facing significant operational challenges across India, particularly highlighted by recent events in Haryana. Healthcare professionals and institutions empanelled under the scheme are grappling with mounting financial pressures and systemic issues that threaten the sustainability of services.

The Crisis in Haryana: A Case Study

Private hospitals in Haryana, represented by the Indian Medical Association (IMA) Haryana, recently suspended Ayushman Bharat services for 19 days, from August 7 to August 25. This drastic step was taken due to persistent issues, primarily delayed and pending reimbursements from the state government.

• Magnitude of Pending Dues: The IMA Haryana reported pending dues of approximately Rs 490-500 crore from the state government. While the government acknowledged some pendency, it stated that it had processed claims up to the first week of May 2025 and utilized Rs 240.63 crore by mid-July 2025. After the initial suspension of services, the Haryana government released Rs 245 crore, but this did not fully appease the private hospitals.
• Worsening Situation Since 2023: This marks the third time in the current year that private hospitals in Haryana have protested against the scheme, indicating a deepening crisis since 2023.
• Impact of Chirayu Yojana: The introduction of the state-specific Chirayu Yojana in 2022, which extends Ayushman Bharat benefits to families with an annual income up to Rs 1.8 lakh, significantly expanded the beneficiary base from 40 lakh to 1.4 crore people in Haryana. This massive increase in coverage has put immense pressure on both the state’s budget and private hospitals.
• Additional Concerns Raised by Hospitals: Beyond delayed payments, hospitals have flagged several other critical issues:
  • Low Package Rates: Existing package rates are considered too low to cover the actual cost of treatment and have remained unchanged since 2021.
  • Arbitrary Deductions and Claim Rejections: Hospitals report heavy and often arbitrary deductions in reimbursements, sometimes as much as 50-90% of the claimed amount, even after prior authorization. Claims are also frequently sent back with “irrelevant queries,” leading to prolonged processing times.
  • Non-Adherence to MoU Terms: The Memorandum of Understanding (MoU) signed with empanelled hospitals stipulates payment within 15 days, with a provision for 1% interest per week on delayed payments. Hospitals allege that the government has consistently refused to pay this promised interest.
• Government’s Stance: State officials have expressed commitment to resolving outstanding issues but have also accused some hospitals of presenting inflated bills and not submitting proper documentation, leading to deductions and rejections. They have also issued warnings of strict action against hospitals that deny treatment to beneficiaries.

Resolution in Haryana

Following a 19-day strike, the IMA Haryana announced the withdrawal of the suspension of services on August 26 after a high-level meeting with the state government, including the Chief Secretary and Additional Chief Secretary (Health). The government committed to a series of corrective measures:

• Timely Claim Settlement: All pending claims will be cleared within 30 days, and a streamlined mechanism will be implemented for future payments.
• Interest on Delayed Payments: The provision for interest on delayed payments under the MoU will be examined in consultation with the finance department.
• Expedited Case Review: Over 400 corrected cases will be processed, and NABH incentive applications will receive priority review.
• Enhanced Support: A dedicated hospital helpline and area-wise training sessions will be introduced to facilitate smoother claim filing and processing.
• Grievance Redressal: Deputy Commissioners across districts have been directed to handle grievance cases more vigilantly and hold regular meetings.
• Withdrawal of Notices: Show-cause or suspension notices issued solely for denying patients during the strike period (August 7-25) will be withdrawn.
• Anti-Fraud Measures: The State Anti-Fraud Unit (SAFU) will expedite pending case reviews and share details of fraudulent activities with hospitals before any de-empanelment action.
• Ongoing Monitoring: Progress on these action points will be reviewed every 15 days, with the next meeting scheduled for October 15.
• Escalation to Centre: Requests regarding package rate revisions, CAPF payments, and “green channel” payment implementation will be escalated to the Central government for approval.

A Wider National Problem

The challenges faced in Haryana are not isolated. The Ayushman Bharat scheme is reportedly struggling across various states, indicating a deeper, systemic issue.

• Significant National Dues: As of February 2025, pending bills for over 32,000 empanelled hospitals nationwide (private and public) have crossed Rs 1.21 lakh crore, with more than 63 lakh claims pending.
• Other Affected States:
  • Manipur: 43 hospitals warned of suspending services due to Rs 80 crore in pending dues over six months.
  • Rajasthan: Private hospitals are owed over Rs 200 crore.
  • Jammu & Kashmir: Hospitals threatened to halt services over Rs 300 crore in pending dues. The situation worsened when the government removed four surgeries from the list for private hospitals.
  • Delhi: Even hospitals that joined the scheme recently are facing payment delays. Major hospital chains like Apollo and Sir Ganga Ram have yet to join.
  • Tripura and Nagaland: Also reported to be in similar difficult situations.
• Impact on Patients Nationwide: Across these states, patients, particularly the economically vulnerable, are being turned away from private hospitals, experiencing cancelled surgeries, and finding public hospitals increasingly overburdened.
• Fraud Concerns: The Ayushman Bharat scheme is also susceptible to fraud. The government reported that over 9.84 crore hospital admissions worth over Rs 1.40 lakh crore were authorized under the scheme. Some states, like Chhattisgarh, have penalized numerous private hospitals for fraudulent and fake claims, with Chhattisgarh logging Rs 120 crore in fraudulent claims, the second-highest after Uttar Pradesh. This has led to the de-empanelment of 1,114 hospitals and suspension of 549 others nationwide.

Conclusion

While the recent resolution in Haryana offers a temporary reprieve, the widespread nature of the crisis underscores the urgent need for a comprehensive overhaul of the Ayushman Bharat scheme’s operational and financial mechanisms. For medical professionals, the ongoing challenges—from delayed payments and arbitrary deductions to inadequate package rates and bureaucratic hurdles—threaten the very ability to deliver critical healthcare services. Sustainable solutions demand not only robust budgetary support and efficient claim settlement processes but also enhanced transparency and trust between government agencies and healthcare providers. Without these fundamental changes, the ambitious scheme risks failing its mission of providing free treatment to the poorest of the poor.