The National Health Insurance Authority(NHIA) has indefinitely suspended two hospitals, Sape Agbo Memorial Hospital and Afatome Klinic both located at Denu in the Ketu District of the Volta Region, from rendering services to NHIS members, for various acts of malpractice including alteration of diagnosis, irrational prescription of medicines, wrongful billing, billing for services not rendered, diagnosis inconsistent with treatment, multiple diagnoses, no records of visits and overstepping limits of accreditation among others.
According to a letter dated May 4, 2010, issued by the NHIA to the affected hospitals, the indefinite suspensions took effect from May 6, 2010 and may be reviewed only when the NHIA was satisfied that the issues which led to the suspensions were rectified.
The NHIA’s action followed clinical and financial audits carried out by the Authority into the operations of the Ketu District Mutual Health Insurance Scheme and five health facilities in the district in March this year, which resulted in the recovery of GH¢982,188 being false claims submitted by five health facilities in the district. The health facilities are Sape Agbo Memorial Hospital, Saint Anthony Hospital, Afatome Klinic, Central Aflao Hospital and Ketu District Hospital under the Ghana Health Service (GHS)
In March this year, the hospitals wrote to the NHIA threatening to withdraw their services to NHIS subscribers with the excuse that they were owed a total of GH¢1,134,332.00 by the Ketu District Health Insurance Scheme. Following that threat, the Authority carried out clinical and financial audits into claims submitted by the facilities and the Ketu district scheme to find out the true state of indebtedness.
The Audits established the actual total indebtedness of the Scheme to the five health facilities to be GH¢614,282.00 and not GH¢1,134,332.00 as previously claimed. The Audit led to the deduction of an amount GH¢462,138.00 as spurious claims from the accounts of the facilities for the period July to December 2009, and also revealed gross incompetence on the part of the management of the Ketu Mutual Health Insurance Scheme. The Scheme failed to deduct GH¢650,284.36 being rejected claims from the five facilities from April 2008 to June 2009
The Audit team also uncovered a fictitious claim of GH¢51,000.00 which was credited to the account of Saint Anthony Hospital by the Scheme Accountant. Further investigations revealed that the Hospital did not submit any such claim. Another revelation was that the scheme failed to vet Claims from the five facilities since April 2008.
At the Saint Anthony Hospital the audit found instances of wrongful diagnosis, mismatch between therapy and diagnosis, non-availability of patients’ folders, fraudulent and wrongful billing, wrongful use of tariffs, and fraudulent charging of patients for claims billed to the NHIS. For example a patient was made to pay GH¢402.70 for consumables, drugs and surgery which the hospital again claimed from the NHIS.
At the Central Aflao Hospital there were instances where out-patient cases were billed as in-patient cases, and there were no records of attendance while some patients’ folders could not be traced. They also imposed co-payments (a practice of asking patients for additional fees to those of the NHIS), multiple billing and over-prescription of antibiotic drugs.
At the Sape Agbo Memorial Hospital, the clinical audit team discovered instances of fraudulent alteration of diagnosis, irrational prescription of drugs, billing for services not rendered, diagnosis not consistent with treatment and wrongful application of tariffs.
At the Ketu District Hospital some patients’ folders could not be traced. There were cases where diagnosis or treatment on the claims forms could not be found in the patients folders. There were also instances of poly-pharmacy, multiple diagnoses, and wrongful billing.
At the Afatome Klinic, the team found the facility to be operating in poor and unhygienic conditions. It also indulged in the billing of drugs not prescribed, wrongful use of tariffs, and multiple diagnoses. The facility was found to have treated conditions above its permissible accreditation level.
Following these findings, the National Health Insurance Authority has suspended indefinitely, Sape Agbo Memorial hospital, and Afatome Klinic from serving NHIS subscribers with effect from the 6th of May 2010. The accreditation of Afatome Klinic would be withdrawn completely after serving the suspension. The Authority has recovered various sums of money totaling GH¢982,188.00 from the five health facilities in the district for the spurious claims they submitted including rejected claims.
The NHIA is taking stringent administrative measures against the Scheme Manager, Claims Manager and the Accountant of the Ketu Scheme whose actions and omissions, managerial incompetence, poor management of claims and fraudulently crediting claims amounting to GH¢51,000 to St. Anthony’s Hospital.