NHIA makes savings through clinical audits (Graphic Business)

TO check fraudulent activities and anomaly within the various District Mutual Health Insurance Schemes (DMHISs) throughout the country, the National Health Insurance Authority (NHIA) has within the past few months embarked on clinical audit of all its facilities as well as its accredited health service providers.
To sustain the exercise, the NHIA has set up a clinical audit unit which has as its members, accounting personnel, auditors, health professionals and administrators to conduct effective auditing.
Information from the NHIA offices in Accra revealed that the authority had recovered more than GH¢6.43m as a result of auditing undertaken within the first quarter of this year.
The clinical audits were conducted in NHIS accredited facilities which included hospitals, clinics and maternity homes and losses were uncovered in instances where service providers inflated prices of medicines and over-billed the schemes for services provided to National Health Insurance Scheme (NHIS) subscribers.
Officials of the NHIA at various functions indicated that the clinical audit exercise had become necessary in view increasing amount of subsidies to the individual schemes.
For example, in 2006 subsidies to the schemes stood at GH¢34.63million, in 2007 the figure rose to GH¢70.10million representing over 100 per cent, again the figure rose to GH¢118.53million in 2008 while in 2009 it hit GH¢333.01million.
It has also been revealed that total reinsurance support paid by NHIA to the various schemes was GH¢0.85million in 2006 rising to GH¢9.17million in 2007, in 2008 GH¢21.55million and last year it rose to GH¢39.85million and it is expected to escalate to GH¢72.50million by the end of this year.
At a recent event in Accra, the Chief Executive Officer (CEO) of the NHIA Mr. Sylvester Mensa said the setting up of the Clinical Audit Unit formed part of measures put in place to block leakage in its claims administration and to ensure sustainability of the NHIS.
“The setting up of the Clinical Audit Unit alongside the strengthening of the Internal Audit Unit and comprehensive regional verification audit checks being implemented were meant to reduce the reported cases of fraud to the barest minimum,” he stressed.
Other measures aimed at checking fraud and abuses of the NHIS programme, according to the CEO included a directive to all schemes to halt the practice of channelling 20 per cent of both subsidies and reinsurance received from the Authority into administrative expenses.
He said a comprehensive plan has been put in place to arrest the escalating expenditures being incurred by the Authority since that development was obviously unsustainable.
Mr. Mensah outlined goals that the Authority has set itself to achieve this year and mentioned a legal review of ACT 650 (2003) and the implementation of the ‘One Time Premium Payment’ as well as the establishment of the first centralised claims processing centre in Accra, which would be replicated subsequently in the regions.
Other targets included an increase of NHIS coverage to 70 per cent of population by Dec 31, 2010 and the promotion of quality of care through accreditation.
There is also plan to establish of a call centre to ensure customer satisfaction.
Mr Mensah in addition announced that the NHIA had reviewed the NHIS medicines list and distributed electronic copies to stakeholders with Coded NHIS medicines, to facilitate electronic claims processing.
Touching on delays in the issuance of ID cards to subscribers, he gave the assurance that a mobile registration and ID issuance terminals would be set up in the near future to address the situation.