Bhubaneswar: The State Health Assurance Society (SHAS), Odisha, has issued a show-cause notice to KIMS Hospital, Bhubaneswar, following a state-level inspection that allegedly detected multiple irregularities under the AB PMJAY-GJAY health assurance scheme.
According to the official notice dated August 25, 2026, the inspection team flagged concerns relating to pre-authorisation, package selection, clinical records, hospitalisation practices, cashless treatment and ICU management.
Pre-authorisation After Discharge
The inspection found that in some cases, pre-authorisation appeared to have been initiated only after beneficiaries had already been discharged. The department has sought verification of system timestamps, admission and discharge records and treatment chronology.
Alleged Up-coding and Clinical Record Issues
The notice also records instances of possible up-coding, where beneficiaries were allegedly admitted or claims were made under higher-value packages that did not appear consistent with the documented clinical condition.
The inspection further raised concerns that indoor case papers in certain cases appeared to correspond with the package blocked rather than the patient’s actual clinical condition.
OPD Cases Allegedly Converted Into IPD
The inspection team also observed that certain cases that could potentially have been managed on an OPD basis appeared to have been admitted as IPD cases without adequate documented clinical justification.
One cited case involved Mrs Kamala Dei, who was reportedly admitted with complaints of myalgia and was receiving oral medication, with no significant documented clinical indication for inpatient admission.
Cashless Treatment Concerns
The notice states that beneficiaries reported being asked to pay for diagnostic investigations and medicines despite being eligible for cashless treatment under AB PMJAY-GJAY.
In the case of Mrs Rutuparna Pradhan, the inspection report records alleged payments of ₹3,560 for diagnostic investigations and ₹1,004 for medicines.
The report also mentions a discrepancy between the beneficiary’s reported period of HDU stay and the period reflected in the system records, raising concerns over possible up-coding and claim inflation.
ICU Staffing and Record Discrepancies
Another major observation concerns ICU management. The inspection team noted that 28 patients were shown as admitted in the ICU, while no Critical Care Specialist/Intensivist was reportedly available at the facility during the inspection. The ICU was stated to be managed by junior residents and interns in the specialist’s absence.
The team also found discrepancies between ICU criteria forms, master charts and admission records in randomly selected cases.
Beneficiary-wise Observations
The notice lists six cases with observations including clinical-record manipulation, up-coding, pre-authorisation after discharge, possible OPD-to-IPD conversion and ICU record discrepancies. The claim amounts listed range from ₹9,325 to ₹94,531.
The hospital has been directed to submit its explanation within five days of receiving the notice, failing which the department may proceed on the basis that there is nothing further to explain and take action as deemed appropriate.
Manipal Hospital Also Facing Allegations
Separately, allegations of irregularities under the Ayushman scheme have also been raised against Manipal Hospital, Bhubaneswar. As reported by Dharani News, the hospital has also been issued a show-cause notice over alleged violations, including alleged collection of money from an eligible beneficiary despite cashless treatment provisions.
The allegations against both hospitals remain subject to their explanations and the department’s further verification.
