STATEMENT BY ACTING CHIEF EXECUTIVE OF THE NATIONAL HEALTH INSURANCE AUTHORITY, SYLVESTER A. MENSAH AT A NEWS CONFERENCE IN ACCRA ON TUESDAY, AUGUST 18, 2009
Ladies and Gentlemen of the media,
We have invited you here this morning to brief you and the general public on some developments regarding the implementation of the NHIS at the provider and scheme levels.
This National Health Insurance Authority (NHIA) is mandated by law to secure the sustainability of the NHIS through prudent financial administration at all levels. The NHIA is also mandated by section 68 of the National Health Insurance Act to assure the provision of good quality of service to members of the NHIS.
Under these mandates, Regional Offices of NHIA have been monitoring NHIS activities at provider sites and the district schemes. Based on the monitoring reports, auditing teams of the NHIA follow up with visits to provider sites and schemes to delve deeper into potential lapses, abuse and wrongdoing that the monitoring unearths. The audit teams comprise professionals with the required expertise and experience in finance, claims and clinical work.
As part of the NHIA’s strategy to increase transparency in all facets of the NHIS, we would from time to time inform the public about steps that are being taken to assure quality of services provided to NHIS members, ensure that providers are reimbursed for only what is genuinely due them and that schemes prudently manage resources under their control.
From the 23rd to 27th of March this year, a clinical audit team from the Authority visited the County Hospital and Atasomanso Hospital, both in Kumasi, Ashanti Region.
We present the findings of the team:
· Double-billing. The hospital billed the NHIS using all-inclusive tariff, that is bills including laboratory investigations. Meanwhile the hospital sent patients to a particular private laboratory and this laboratory billed the NHIS as well.
· Over-billing and non-adherence to tariffs. The present Tariff structure allows three visits within a 2 week period to promote quality of care. Unfortunately, some providers have been billing NHIS three times even though patients did not visit the facility three times within the 2 week period. For patients who attended the hospital only once, the hospital put in claims for two visits on the same form. The clinical notes however did not show evidence of a second visit. Others had two claims put in for one visit. A patient with Urticaria, after receiving treatment was detained for a few hours yet the hospital claimed for severe infection requiring several days’ admission. The treatment with few hours detention costs GH¢ 29.60 whereas treatment for the severe infection cost GH¢136.60. The hospital also gave a patient 16 bags of 500mls Intravenous Infusion fluids but billed the Scheme for 37 bags.
· Irrational prescribing and Polypharmacy. The Hospital gave patients 4 different kinds of antibiotics at the same time. Some other patients were started with a set of two antibiotics and were, a few days later, changed to another set of two. The same patients were seen one week after and given the first two antibiotics again.
· Non adherence to the Medicines list. Patients were given medicines outside the NHIS Medicines List for which the schemes paid. Where prices of such medicines were higher than their substitutes on NHIS Medicines List, members were made to pay top-ups contrary to NHIS policy and guidelines.
· Poor quality care and unsupported claims. The hospital diagnosed psychosomatic disorder for about 60% of patients who visited there. In fact, it diagnosed this more than malaria which is the commonest condition seen at primary care levels. The hospital then treated the patients with the most expensive anti-stomach ulcer medicine on the medicines list. The medicine, Rabeprazole is given once daily which amounts to 60 tablets for a 2 months course at a cost of GH¢128.40 per person. None of these patients was made to undergo endoscopy to show if an ulcer was present.
· Polypharmacy. Most of the patients had an average of 7 medicines given at outpatient visit. Many times the diagnosis for which the claim was made did not match the medicines given e.g. admission for severe malaria but no anti-malarials and no laboratory investigation showing malaria.
· Double billing. Many claims showed double billing for the same drug given on the same day. E.g. Intravenous Ciprofloxacin was listed as the first item and also the fourth item on the claims form for the same on the same day.
· Over billing. A diabetic on admission was given 40 units of insulin daily for 5 days amounting to 200units. The claims form indicated 6 vials amounting to 2400units. That was an overcharge of 2,200 units.
· Fraud. In some instances the Hospital claimed wrong and higher tariffs for diagnoses but the clinical notes did not match this. For example one patient was allegedly admitted by the hospital for abdominal pain but no surgery was performed. The hospital charged the scheme for severe infection at a cost of GH¢158.90 instead of sending a bill for non-specific abdominal condition at a cost of GH¢43.70. In another instance the hospital admitted a patient for 10 days. However on the claims form the hospital put in an additional bill for 3 outpatient visits for the same patient who was on admission. These outpatient visits included medicines which were supposedly prescribed and dispensed.
Ladies and gentlemen of the media, clearly, the activities of these two hospitals constitute serious financial leakages on the Scheme that must be stopped. It is worth noting that the two hospitals appealed against the decision and the NHIA’s findings were subjected to a review by healthcare professionals drawn from the private and public sector. The review upheld the NHIA findings.
Management has therefore decided to sanction the aforementioned facilities as mandated by the National Health Insurance Act. Effective from 14th August 2009 through 13th November 2009, the Atasomanso Hospital and the County Hospital both in the Kumasi metropolis have been suspended from providing services to NHIS subscribers for a period of three months. All NHIS members therefore should desist from visiting the two facilities for medical care as cases attended to during the period of suspension will not be reimbursed by the schemes.
Ga District Mutual Health Insurance Scheme, Amasaman, GAR
Ladies and gentlemen, at the Scheme level, financial and claims audits done on the Ga Mutual Health Insurance Scheme covering the period 1st January 2007 to 31st December 2008 revealed several anomalies ranging from misapplication of funds, inability of the scheme to account for monies, poor controls/conflict of interest and weaknesses in organizational processes as well as outright incompetence on the part of the management of the scheme. Below are some highlights:
· Amasaman Hospital is a public district hospital but the facility used the tariffs for private district hospitals during April-July 2008. This anomaly was not detected by the management of the scheme as the Claims Department of the scheme did not vet claims from the major service providers. The situation resulted in the overpayment of claims to Amasaman Hospital
· A total of GH¢776,259.39 was paid out of the claims account for expenses not related to claims. In effect, this huge amount was used for the payment of administrative expenses, instead of claims which the monies were meant for.
· Some payment vouchers regarding claims payment for July 2008 (GH¢426,362.61) and November 2008 (GH¢404, 809.64) respectively could not be traced at the time of the audit. Scheme management is yet to make these payment vouchers available.
· The Scheme paid GH¢14,260 from petty cash in May 2008 as 2 months allowance for 23 National service persons (NSP) representing GH¢620 per head. No petty cash voucher was raised. Instead a schedule of the names and signatures of the NSPs, as well as the amount paid was recorded on an A-4 paper. The audit revealed that the National Service personnel were paid GH¢62.00 each and not GH620.00. The Accountant admitted that it was a mistake and that he paid GH¢62 per person but recorded GH¢620.00. The difference could not be accounted for.
· The Scheme paid GH¢30,000 as rent advance for new offices for a five- year period, beginning 21st November, 2008. As at now the Scheme has not relocated to this new building because it has not been completed.
· The Scheme has failed to account for a shortfall in the premiums received from collectors amounting to GH¢9,558.78.
· 274 out of a total of 954 receipt books issued to collectors between January 2007 and June 2008 had not been accounted for by the Collectors. Thirty-five (35) of the said receipt books were issued to collectors for mass registration in February and March 2008. The inability to account for the receipt books was due to poor monitoring and control by the Scheme’s management.
· Bank reconciliation statements (BRS) were not prepared during the audit period except for November 2008 when the Scheme filed for reinsurance.
· Weaknesses were also found in the Scheme’s procurement procedure: Though there was a Tender Committee in place, most procurement had no evidence of the work of this committee. A total of GH¢335,170 was spent on printing materials within 2 years without the involvement of the Committee. Furthermore, there was no evidence of receiving and checking of goods when supplied.
· Six (6) non-permanent staff of the Scheme were given loans amounting to GH¢2,250.00. These persons were not on the payroll and their loan repayments could not be traced in the cash book.
· The financial audit found instances that suggest fraud. For example, two of the three invoices obtained for the procurement of printing materials, which were supposed to have come from different sources had the same postal address and telephone number. There was also an instance where GH¢750.00 was recorded as the amount spent on fuel though the correct amount was GH¢75.00. Similarly, a figure of GH¢40.00 was changed to GH¢100.00 as fuel allowance for the MIS Manager.
· The Scheme did not have a limit for petty cash disbursement. As a result, as much as GH¢9,000.00 was paid with cash for printing materials.
· There were no payment vouchers to cover administrative and petty cash disbursements; recipients did not acknowledge receipt of monies paid to them.
In view of these findings, the Authority has directed that the Manager and Accountant of the Ga District Health Insurance Scheme should step aside for thorough investigations into the operations of the scheme.
Ladies and gentlemen, the NHIA is fully committed to ensuring efficient financial management at all levels of implementation of the NHIS and provision of quality care to NHIS members. It is for this reason that it takes a serious view about the matters being reported to you today.
I dare say that the NHIA will deploy all means at its disposal to ensure that perpertrators of acts that seek to undermine the sustainability and integrity of the NHIS as well as compromise the quality of care offered NHIS members are brought to book.
I wish to stress that the audits that we have conducted and continue to conduct are not a witch hunt, but an effort to ensure that the resources and safety of the public are protected and I believe the media will pledge its support to this effort.
In the meantime, we do not take for granted the enormity of the task facing not the NHIA alone, but the nation at large to ensure that we protect this key national effort at improving access to healthcare for all residents of this country, and we believe with your assistance, the nation will be effectively informed about the NHIS.
May I at this moment announce that work on the introduction of the one-time premium payment for health insurance is far advanced and it is our expectation that Government’s promise in this regard will be fulfilled.
May I also announce that a policy review of the NHIS to align the policy to current needs has begun and we shall be communicating with you on the review as it progresses.
Thank you for your attention.