Dealing with Health Insurance Fraud,
Abuse & Waste
GHANA’S PERSPECTIVE
Reforms in Ghana’s Health
1957
Free health care policy implemented.
1970s
Ghana experienced economic shocks and began structural
adjustment programmes.
Nominal payments for health services introduced.
1985
User fees (cash & carry) was introduced. This policy excluded
majority of people from access to healthcare
1990s
Community-based mutual health insurance schemes were
introduced.
2000
High out-of-pocket expenditure on health and very low
utilization of health services.
2003
National Health Insurance introduced.
BACKGROUND
Your access to healthcare
•
•
•
The NHIS was established by an Act of
Parliament in 2003 (Act 650).
Initiative by Government to secure financial risk
protection against the cost of healthcare services
for all residents in Ghana.
Act was revised in 2012 – NHIS Act 850
Funding - Combination of the following models
Bervridgian: National Health Insurance levy - 2.5% VAT
Bismarkian: 2.5 percentage points of Social Security contributions
MHO: Graduated informal sector premium based on ability to pay
Earmarked funds (NHIL & SSNIT) constitute over
90% of
• total inflows
Benefit package covers 95% of disease
conditions
Key Players in NHIS Architecture
MINISTRY OF
HEALTH
(MOH)
PROVIDERS
(Public &
Private)
Provision of
quality
services
4
Stewardship
(Policy & Regulation)
Submission of Claims
PURCHASER
(NHIS)
Payment of Claims
Utilization
of
services
SUBCRIBER
Pays
Premium
Ensure
provision of
quality
services
ACTIVE MEMBERSHIP
Your access to healthcare
NHIS Payments v Cash payments
100%
90%
80%
Your access to healthcare
70%
60%
NHIS
Payments
50%
40%
30%
20%
10%
0%
2006 2007
2008 2009
CASH
Payments
2010
2011
2012
2013
Definition
Your access to healthcare
HEALTH CARE FRAUD
• Health insurance fraud is described as
an intentional act of deceiving,
concealing, or misrepresenting
information that results in health care
benefits being paid to an individual or
group.
• Fraud can be committed by
subscribers, providers and health
insurance staff
MOTIVATORS
Motivators –
Your access to healthcare
TYPES OF FRAUD
Types of fraud - Providers
Your access to healthcare
Billing for services not rendered
Up-coding of services- DRG payments
Double billing/Duplicate claims
Misrepresentation of diagnosis
Unbundling of services
Unnecessary services
Inappropriate referral for financial gain
Insertion/Substitution of medicines
Unauthorised co-payments
Recycling old claims
Unaccredited facilities submitting through
accredited facilities
Types of fraud - Subscribers
Your access to healthcare
Impersonation – a non-member using
a member’s identity
Ganging – all the family using one
member’s card
Provider shopping
Illegal cash exchange for
prescriptions
Types of fraud- Health Insurance Staff
 Registering
Your access to healthcare
subscribers in exempt
category thereby waiving premium
Fast tracking membership thereby
increasing adverse selection
 Passing fraudulent claims from
providers for kickbacks
PREVENTION/MITIGATION
Ways to prevent/mitigate abuse
Policy
• Biometric
registration
• Payment
mechanisms
Pre-payment
• Effective
claims
processing
• Claims
Processing
Centres
Postpayment
• Claims
verification
• Compliance
audit
• Clinical
audit
Policy methods
• Biometric registration
• Biometric authentication at point of
service
• Capitation for Primary care services
• Fee-for-service for medicines
• DRG for specialist OPD , in-patient
and surgical care
Pre-payment methods
Effective claims processing
Claims Processing Centres - consolidation
Membership – biometric authentication
generates a Claims Check Code
Treatment protocols – diagnoses linked to
treatment
Adherence to National Standard Treatment
Guidelines
Adherence to National Prescribing &
Dispensing levels
Electronic vetting business rules – logical &
business rules
Claims Processing
Provider
Payment
Eligibility &
Membership
Paper
claims
E-vetting &
E-adjudication
CPC
CLAIMS
SOFTWARE
G-DRG
ICD-10
E-claims
Treatment
Protocols
Statistical Data
Comparing Claims Adjustments at CPC to
Nationwide (2013)
12%
11%
10%
8%
6%
2%
0%
4%
3.50%
4%
2%
3%
2%
3%
4%
3%
2%
1%
Post-payment methods
• Claims verification – suspicious claims
within 2 months of processing
• Compliance audit – verify claims data –
attendance, utilisation,
• Clinical audit – assess quality of care,
adherence to treatment protocols,
appropriate staffing at facility
Regional claims data 2012-June 2013
IPD & OPD Utilisation per active member
8.15
3.68
3.13
3.28
3.63
3.23
3.07
3.06
3.01
2.66
2.49
2.87
2.53
2.36
2.68
2.89
2.58
2.11
0.15
0.09
0.08
0.15
0.15
0.05
0.04
0.17
0.22
0.12
0.19
0.27
0.03
0.09
0.21
0.17
0.10
-
WAY FORWARD
Way forward - Incentives
Encourage whistleblowers
Early reimbursement for providers
with clean claims.
% tariff increase for adherence to
treatment protocols
Increased advocacy and
sensitisation on the impact of fraud
and abuse on the health insurance
system
Way forward - Deterrents
Pass specific health insurance fraud laws
making it a criminal offence e.g. USA
Health Insurance Portability and
Accountability of 1996 (HIPAA)
Financial penalties above repayment
of fraudulent payments
Health care provider should lose its
license with the regulatory bodies as
well as disaccreditation by the insurer
Public gazetting of fraud and abuse
cases
Conclusion
• Health Insurance fraud is a global phenomenon
• It cannot be eliminated entirely but can be
minimised
• Methods to prevent fraud is insurance scheme and
country specific although there are general
measures that can apply to all
• There will always be loopholes in the medical
scheme.
• Each time a loophole is closed, another is found.
• Insurers need to work with providers and members
if the prevention methods are to be successful.
THANK YOU