NHIA recoups GhC20m from fraudsters

A string of financial inconsistencies had auditors asking questions at the National Health Insurance Agency (NHIA). The NHIA is quickly growing into one of Ghana’s largest and most profitable insurance companies.

With a flood of money flowing in, some are worried that white-collar crime is inevitable after the NHIA recovered a total of more than 20 million cedis from hospitals and health service providers found to have made fraudulent claims in medical bills nationwide.

Records found in the NHIA archives demonstrate what one unnamed official is describing as “a network of over 100 private and public hospitals and their associates, using fake documents and in some cases exaggerating medical bills, or prescribing expensive medicines in order to make fake but hefty claims for treating patients in the Ashanti region. ”

The total of these alleged frauds has yet to be released, but some in the agency are confirming the NHIA is hemorrhaging millions monthly in the Ashanti region alone.

For instance, the offending pharmacies and health facilities billed the NHIA not less than 50. 1 million cedis for medications purportedly provided to subscribers partly in the year 2010 and 2011. Clinical audits conducted by the NHIA in those years, after paying a little above 47 million cedis of the 50-million-cedi claims, revealed that the providers were overpaid by as much as nearly 6 million cedis.

Complicit in frauds Evidence has surfaced that members of the hospital staff may be complicit in the frauds, even distributing controlled drugs through pharmacies in some areas. Some hospitals in the region are suspected of lying thousands of times in order to receive millions of cedis for medical services never rendered. In addition, some of the offending hospitals hired people to bill the NHIA for medical services that they ostensibly rendered to patients whom they knew they never treated.

Many documents exhibit multiple layers of fraudulent behavior being perpetrated by public and private hospitals in the region. The paperwork also exposed yawning inconsistencies such as doctors specializing in nose and throat performing pregnancy ultrasounds and dermatologists giving heart examinations.

The NHIA initiated the investigation exposing a number of in-house fraudulent practices. However, authorities have been slow to act. In some cases, NHIA did compel some aberrant facilities to return ill-gotten money, but the majority of tax dollars has not been recovered. The top 12 fraudulent claims robbed the NHIA of nearly 3. 5 million cedis in the Ashanti region alone.

The biggest fraud against the NHIA was committed by a respected public hospital in the Ashanti region. In 2010, the hospital submitted a bill of more than 3,400,356. 18 cedis to the NHIA. The bill was categorized as the cost of treating subscribers.

However, the NHIA – after paying nearly 3. 4 million cedis to the state-owned hospital – found that it was overbilled by as much as 2. 1 million cedis and ordered the hospital to return all fraudulent payments.

A year later, in September 2011, the NHIA ordered authorities at a private hospital in the region to cough up nearly 290,000 Ghana cedis the facility received after making bogus claims. This was the second time the hospital had been caught for fraudulent billing practices.

In 2009, the NHIA demanded the hospital return nearly 130,000 Ghana cedis received in bad-faith. The preceding are just a few on a growing list of suspicious and fraudulent activity.

Insiders are saying, only 12 percent of the cedi assumed lost in frauds has been returned. The NHIA is facing an urgent need to adopt more proactive and advanced analytic techniques in order to protect premiums from skyrocketing.

The controversial pilot capitation grant policy was a bold attempt to regulate the behavior in Ashanti hospitals. The capitation policy, which is aimed at cutting down cost in the National Health Insurance Scheme (NHIS), is currently being piloted there for future replication across the country. But, the policy has encountered resistance from service providers and sparked demonstrations by the Asante Development Union.

Strong reaction Per the new policy, subscribers of the NHIS would need to identify three health-care facilities they would seek services from. The NHIA would then provide funding based on the number of patients registered with the institution.

The new policy has provoked a strong reaction from the ADU. The group released a statement demanding the plan be scrapped. And last month echoed their demand with threats of demonstration. In response, officials of the NHIA, led by the director of research, O. B Acheampong, organized a meeting with the leadership of the ADU seeking their support.

The meeting ended in a deadlock. The ADU then moved the debate to the streets. Carrying placards, some of which read; “Why capitation in the Ashanti region”, “Capitation is killing us slowly”, “Atta don’t kill the people of Ashanti Region with capitation” and “Sylvester must go”, the group presented a petition to the Regional Manager of the NHIS and called for an end to the policy.

Right now, the NHIA is targeted at ending frauds in the region and argues capitation is the most effective method to reach that goal.