Tackling Fraud and Unofficial Payments within the NHIS

By Dr. Cynthia Bannerman, Deputy Director Quality Assurance, Ghana Health Service

(This blog is cross-posted from The Joint Learning Network with permission) - Fraud, abuse and unofficial payments are threats to the sustainability of health insurance schemes. Over the last two years, Ghana’s National Health Insurance Authority (NHIA) has recouped 18 Million Ghana Cedis ($7.4 Million USD) charged through fraudulent claims by service providers.

We know that fraud and abuse are not unique to Ghana, and can never be completely eliminated. However, interventions must be put in place to prevent and reduce their occurrence. The Joint Learning Network for Universal Health Coverage (JLN) Ghana Country Core Group is taking the initiative to mitigate this risk and strengthen the identification and detection of fraudulent activities by developing a Manual to help scheme staff and health managers more easily identify fraud, and provide guidance on methods of prevention.

Sharing knowledge to prevent fraud and abuse

The NHIA is trying to deter fraudulent activities by establishing a Clinical Audit Division, consolidating Claims Processing, and introducing e-claim. This year, they will roll out a biometric registration system to authenticate the identity of cardholders. But, there is more work to be done not only by the NHIA, but other stakeholders including the Ghana Health Service (GHS), the Ministry of Health (MoH), Providers, and Subscribers.

With the aim of providing an open discussion forum for both public and private stakeholders the JLN Ghana Country Core Group organized a workshop on “Fraud and Unofficial Payments” on Wednesday, February 5 to discuss how increased public education, greater penalties for false claims and more analysis of claims data could help prevent abuse.

“The JLN is an open forum for sharing, learning, and identifying areas where the Core Group can collaborate to improve the NHIS,” said Dr. Cynthia Bannerman, Deputy Director Institutional Care Division for Ghana Health Service and Chair of the Ghana Country Core Group as she welcomed 30 participants from the NHIA, GHS, MoH and other organizations to the meeting. “This is not a forum to place blame, but rather an opportunity to identify solutions.”

Dr. Lydia Dsane-Selby, Director of Claims for the NHIS and Mr. Philip Akanzinge shared examples of how providers and scheme staff defraud the scheme such as the case of a public and private facility with the same doctor where 1,524 patients visited both facilities exactly one month apart. This doctor's fraudulent claims cost the scheme nearly $500,000 USD. Luckily, most of the funds were recouped after the fraud was identified through clinical audit. More common versions of fraud include facilities recycling claims from month-to-month and the sharing of patient details between facilities.

“E-claims are the best method to prevent fraud and abuse,” explained Dr. Dsane-Selby. “It will allow us to track eligibility, link diagnosis and treatment, and provide statistical data to support evidence-based decision making.”

Mr. Akanzinge focused on the many forms of unofficial payments besides duplicate charges such as collusion between schemes and providers, inaccurate prescriptions, and charging patients for covered services.

“We have seen many cases where the provider will submit a claim for a month's worth of prescription medicine, but only give the patient enough medication for half of the month,” said Dr. Akanzinge.

A vibrant discussion followed the presentations with participants sharing their own experiences with fraud within the scheme and personal opinions of how to thwart the abuse. A common theme that began to emerge from participants was the need to provide more education and guidance to subscribers, scheme staff and stakeholders with regards to how they can spot fraud, report fraud, and their rights as subscribers.

Drawing on the joint-learning approach the group decided to pool their collective ‘know how’ to develop a Manual on Fraud and Abuse to serve as a Ghana-specific resource for NHIS stakeholders. The sub-committee plans to meet in the coming weeks to develop an outline and detailed work plan.

Ongoing Joint Learning and Collaboration

In addition to forming a sub-group to move forward with the Manual on Fraud and Abuse, the Core Group also identified other opportunities for collaboration that could streamline the flow of data between the NHIA and GHS, and allow them to collaborate more effectively with the University of Ghana for data analysis. There was also overwhelming agreement that a sub-group should be formed to develop a Ghana-specific Costing Manual – to support capitation – using the JLN Costing Manual.

The JLN Country Core Group – now 50 members strong – plans to meet in the second quarter of 2014 to discuss enforcement of the benefits package, rationale prescribing and the use of antibiotics, or district management information systems.

The team would like to hear what other JLN member countries are currently doing to identify fraud and unofficial payments, and what steps they have taken to prevent further abuse. If you would like to provide input into this Guide post in the comments or email Nkem Wellington at [email protected].

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