The Public Accounts Committee (PAC) of Parliament has charged managers of the National Health Insurance Scheme (NHIS) to fully retrieve its misappropriated funds.
“The Committee therefore urges the National Health Insurance Authority (NHIA) to ensure that funds misappropriated are fully recovered with interest… the NHIA should restructure its operations to ensure an efficient and effective claims management within the National Health Insurance Scheme,” PAC recommended in its 11-page report submitted for adoption to Parliament.
A total amount of GH¢28.4 million, according to the report has been misappropriated by the scheme.
Christened: “Performance Audit report of the Auditor-General on the Management of Claims by the National Health Insurance Scheme (NHIS)” and signed by the Chairman of PAC, Kwaku Agyeman-Manu, the report stated that the misappropriation of the fund was discovered after a clinical audit of the scheme in February 2010 on 164 Health Service Providers (HSPs).
GH¢6.4 million of the amount represented the total misappropriation that occurred under the scheme with GH¢22 million occurring as a result of over payment to the HSPs.
“Officials of the NHIA informed the committee that the misappropriation occurred mostly through malpractices such as the insertion (in the claims form) of drugs not prescribed, creation of claims in respect of persons who did not attend hospital, overstatement of claims, prescriptions not serialised, among others,” the report stated.
The amounts, the committee explained, were paid without recourse to section 16(1) of the Internal Agency Act, 2003 (Act 658) for the necessary auditing to be done on the claims.
This occurred because the District Mutual Health Insurance Schemes (DMHIS) have no Internal Audit Schemes to counter-check claims.
According to the report, the misappropriation might have occurred largely as a result of the lack of requisite training and skills of DMHIS staff.
“As indicated in the Auditor-General’s report, 26 out of 28 claim Managers at the DMHIS interviewed had difficulties in the vetting processes; especially in the area of matching prescription with diagnosis…,” a situation which the PAC described as bringing the competences of the managers into disrepute.
Parliament was compelled to go into the activities of the 2003 founded NHIA following reports of claim mismanagement by the Auditor-General in his Performance Audit Report presented to the House on 18th July, 2013.
It further invited officials of the Ministry of Health, Ghana Health Service, National Health Insurance Authority and the Christian Health Association of Ghana to help in the investigations of Parliament.
The report however stated the NHIA recognising their mistake in the doling out of moneys to HSPs have recovered GH¢8.4 million out of the GH¢22 million misappropriated to its fold; it has also instituted actions to recover the rest of these monies.
“To recover the funds misappropriated, the NHIA has, for instance, through the Attorney General, instituted ten (10) criminal prosecutions against culprits…,” it assured.
Of the number, eight of them are still on-going in court with two being discontinued.
On overpayment, officials of the NHIA who were invited by the committee for interrogation said plans are underway to not only recover but al so stop the occurrence of such high level of embezzlement of the scheme’s money.
“An officer of the NHIA who was found to be involved in the overpayment of claims has been convicted by the courts. Furthermore, about 100 HSPs who were found wanting in the clinical audit have had their accreditation withdrawn by the NHIA,” the report assured.
The United States Agency for International Development (USAID) was named as an agency which was currently helping the USAID to double its clinical audit efforts to help detect and deter wrongful billing, wrongful claims and overpayments.
“Some categories of staff of the NHIA are also being trained in the vetting of claims…the NHIA has introduced an E-claims system which is currently being piloted in forty-seven (47) hospitals to facilitate electronic vetting.
These notwithstanding, the committee urged the body to pursue the court cases with the seriousness it deserves and also build the capacity of its officers in charge of vetting and paying claims especially in the area of matching prescriptions to diagnosis.
A second observation which the PAC, per the report, discovered was the delays in the payment of claims to HSPs by the DMHIS, an issue which was said to be contrary to Regulation 37 (7) and Regulation 38 (1) of the NHIS Legislative Instrument (L.I 1809) that stipulate that HSPs be paid within 60 days from the discharge of patients or the rendering of the service and 4 weeks after the receipt of the same respectively.
“In 2009 for instance, payment of claims were delayed for periods ranging from 3 to 6 months. The Committee noted that as at its sitting on the 20th of August 2013, claims by the Christian Health Association of Ghana had been settled up to March 2013.”
Officials of the NHIA informed the committee members that delays in claims submission by HSPs to DMHIS and delays in claims vetting by the District Offices as well as the problem of Cash flow due to lack of prompt payment by government are the causes.
They mentioned that the NHIA has established four (4) Claims Processing Centers in Accra, Kumasi, Tamale and Cape Coast to ensure effective management of the claims vetting and payment processes from the Regional, District and selected Private HSPs.
“Again, the deployment of E-claims System at the Provider sites will also facilitate electronic submission of claims.”
On cash flow from Government to NHIA, the committee recommended that the Ministry of Finance and Economic Planning ensures that the release of National Health Insurance Levies and SSNIT contributions to the NHIA are made with due regard to the National Health Insurance Act, 2003 (Act 650) in order not to affect the operations of HSPs.
It further recommends the NHIA to update its use of Information Communications Technology (ICT) for on-line acceptance and vetting of claims so as to reduce significantly, delays in claims payment.
To minimize the risk of waste and fraud, the committee proposed internal control mechanisms to be instituted in all district and regional offices to include pre-auditing of all claims before payments are made.
The NHIA, the committee said, should also update its computer systems to capture batch and serial numbers of valued books obtained from the Controller and Accountant General’s Department (CAGD) and also reconfigure its ICT interface in use at the NHIA and DMHIS so as to detect or query double entry of the same information.
Against this backdrop, PAC urged Parliament to adopt its Report on the Performance Audit report of the Auditor General on the Management of Claims by NHIA.