Mr. Sylvester Mensah, CEO of NHIS
Loading
10th May, 2010
MASSIVE FRAUD IN KETU NHIS... 2 Hospitals Suspended
THE sustainability of the National Health Insurance Scheme (NHIS) in some parts of the country, is under threat, following massive fraud being perpetrated by some service providers.
A clinical and financial audit carried out by the National Health Insurance Authority (NHIA) into the operations of the Ketu District Mutual Health Insurance Scheme and five health facilities in the district in March this year, has led to the recovery of GH¢982,188 being false claims submitted by the five hospitals.
The Deputy Director of the NHIA in charge of Corporate Affairs and Strategic Direction, Mr Eric Ametor Quarmyne who disclosed this to the Times in Accra on Friday said two of the five health facilities have consequently been suspended indefinitely from rendering services to the NHIS members.
He named the suspended hospitals as Sape Agbo Memorial Hospital and Afatome Clinic, both at Denu in the Ketu District of the Volta Region.
The others involved in the deal include St. Anthony Hospital, Central Aflao Hospital and Ketu District Hospital.
According to Mr Quarmyne, the hospitals wrote to the NHIA in March this year, threatening to withdraw their services in the NHIS subscribers because they were owed a total of GH¢1,134,332.00.
Following that threat, he said the Authority carried out the audit into the claims submitted by the facilities and the Ketu district scheme to find out the true state of the indebtedness.
“The audits established the actual total indebtedness of the scheme to the five health facilities to be GH¢614,2282.00 and not GH¢1,134,332.00 as previously claimed,” he said.
Consequently, he said the audit led to the deduction of GH¢462,138.00 as spurious claims from the amount of the facilities for the period between July and December 2009 and also revealed gross incompetence on the part of the management of the Ketu Mutual Health Insurance Scheme.
For instance, he said the scheme failed to deduct GH¢650,284.36, being rejected claims from the five facilities from April 2008 to June 2009.
He said the audit also uncovered a fictitious claim of GH¢51,000.00 which was accredited to the account of St. Anthony Hospital by the scheme Accountant among other irregularities.
At the St Anthony Hospital, he said the audit found instances of wrongful diagnosis, mismatch between therapy and diagnosis, non- availability of patients folders, fraudulent and wrongful billing and fraudulent charging of patients for claims billed to the NHIS.
At the Central Aflao Hospital, Mr Quarmnyne mentioned instances where out-patient cases were billed as in patients.
At the Sape Agbo memorial Hospital, he said the audit team discovered instances of fraudulent alteration of diagnosis irrational prescription of drugs and diagnosis not consistent with treatment.
Mr Quarmyne said the NHIA was taking stringent administrative measures against the scheme manager, claims Manager and the Accountant of the Ketu Scheme whose managerial incompetence led to that.
A clinical and financial audit carried out by the National Health Insurance Authority (NHIA) into the operations of the Ketu District Mutual Health Insurance Scheme and five health facilities in the district in March this year, has led to the recovery of GH¢982,188 being false claims submitted by the five hospitals.
The Deputy Director of the NHIA in charge of Corporate Affairs and Strategic Direction, Mr Eric Ametor Quarmyne who disclosed this to the Times in Accra on Friday said two of the five health facilities have consequently been suspended indefinitely from rendering services to the NHIS members.
He named the suspended hospitals as Sape Agbo Memorial Hospital and Afatome Clinic, both at Denu in the Ketu District of the Volta Region.
The others involved in the deal include St. Anthony Hospital, Central Aflao Hospital and Ketu District Hospital.
According to Mr Quarmyne, the hospitals wrote to the NHIA in March this year, threatening to withdraw their services in the NHIS subscribers because they were owed a total of GH¢1,134,332.00.
Following that threat, he said the Authority carried out the audit into the claims submitted by the facilities and the Ketu district scheme to find out the true state of the indebtedness.
“The audits established the actual total indebtedness of the scheme to the five health facilities to be GH¢614,2282.00 and not GH¢1,134,332.00 as previously claimed,” he said.
Consequently, he said the audit led to the deduction of GH¢462,138.00 as spurious claims from the amount of the facilities for the period between July and December 2009 and also revealed gross incompetence on the part of the management of the Ketu Mutual Health Insurance Scheme.
For instance, he said the scheme failed to deduct GH¢650,284.36, being rejected claims from the five facilities from April 2008 to June 2009.
He said the audit also uncovered a fictitious claim of GH¢51,000.00 which was accredited to the account of St. Anthony Hospital by the scheme Accountant among other irregularities.
At the St Anthony Hospital, he said the audit found instances of wrongful diagnosis, mismatch between therapy and diagnosis, non- availability of patients folders, fraudulent and wrongful billing and fraudulent charging of patients for claims billed to the NHIS.
At the Central Aflao Hospital, Mr Quarmnyne mentioned instances where out-patient cases were billed as in patients.
At the Sape Agbo memorial Hospital, he said the audit team discovered instances of fraudulent alteration of diagnosis irrational prescription of drugs and diagnosis not consistent with treatment.
Mr Quarmyne said the NHIA was taking stringent administrative measures against the scheme manager, claims Manager and the Accountant of the Ketu Scheme whose managerial incompetence led to that.
Popular stories from Front Page News
