REFORMS AT NHIS

...clinical audit recovers ¢170bn

...service providers being paid on time

By Nana Yaw Boateng

Daily Post can unequivocally reveal that clinical audit undertaken by the National Health Insurance Authority (NHIA) since the Mills Administration came to office has led to the recovery of a whopping GH¢17 million (¢170 billion cedis) being fraudulent claims submitted by dubious service providers.

According to sources at the NHIS, from January to June this year, with just 33 schemes out of 145 clinically audited, the Authority has recovered a whopping GH¢4,965,326.74.

Clinical and financial audits under the current leadership have also enabled the Authority to expose thieving scheme staffers who have engaged in financial malpractices and fraud to face the full rigours of the law.

For the five years that the scheme was implemented under the Kufuor Administration, not even one external auditing took place to ensure that financial malfeasance was nipped in the bud.

The resultant effect of this was that people dipped their hands into the coffers of the schemes and dissipated funds which they (schemes) had generated from premium collections or which were sent to them by the Authority for the payment of claims and for administrative purposes.

Some also diverted such funds into private accounts which they opened at various banks.

Sources at the Authority told this paper that claims payment to service providers constituted the highest single item of cost in the expenditure of the NHIA.

They revealed that in 2008, a total amount of GH ¢165 million was spent on claims payment countrywide and that by December 2009, the claims had more than doubled.

This trend of expenditure, the sources observed, could not be sustained into the future “so Management decided to verify the reasons and sources of the exponential increments in claims cost and how to contain them.”

Consequently, a Fraud and Clinical Audit Unit has been established within the NHIA to undertake claims verification across the country to ensure that the Authority pays for only what it really has to pay.

This, according to the sources, led to the recovery of the said colossal amount.

Confidential documents sighted by this reporter shows that the New Patriotic Party (NPP) government under Mr John Agyekum Kufuor deliberately or otherwise refused to make available to the NHIA, proceeds from the National Health Insurance Levy (NHIL), which had accumulated to some GH¢115,000,000 (¢1,150,000,000,000 ) by December, 2008.

As a consequence, the financial state of affairs of the Schemes, Daily Post has learnt, in relation to their indebtedness to the various service providers across the country was precariously at the tip of a needle at the time the National Democratic Congress (NDC) team took office.

Further checks conducted by this reporter have established that many service providers at the time were owed huge sums of money for long periods of time, some stretching to over a year.

This phenomenon led to a state of hopelessness among the over 5,000 service providers who have been accredited to provide healthcare services to NHIS card bearers.

The culminating effect of all this was that NHIS subscribers were either turned away from healthcare facilities or were unduly delayed in accessing healthcare or were attended to in a hostile manner.

According to a senior staffer at the NHIA, the situation had dismally affected the operations of the service providers, as they in turn could not fulfill their financial commitment to their suppliers.

As a result of these developments, the service providers lost trust in the ability of the Schemes to fulfill their mandatory requirement of making payment within the 90 days as stipulated in Act 650 of the NHIS act, culminating in a total lack of discipline in the schemes.