Ghana’s Perspective

1. Dealing with Health Insurance Fraud, Abuse & Waste Ghana’s Perspective

2. Reforms in Ghana’s Health 1957 Free health care policy implemented. Ghana experienced economic shocks and began structural adjustment programmes. Nominal payments for health services introduced. 1970s 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.

3. Your access to healthcare BACKGROUND • 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

4. Key Players in NHIS Architecture MINISTRY OF HEALTH (MOH) Stewardship (Policy & Regulation) Submission of Claims PURCHASER (NHIS) PROVIDERS (Public & Private) Payment of Claims Utilization of services Pays Premium Provision of quality services Ensure provision of quality services SUBCRIBER

5. Your access to healthcare ACTIVE MEMBERSHIP

6. Your access to healthcare NHIS Payments v Cash payments

7. Your access to healthcare Definition 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

8. MOTIVATORS

9. Your access to healthcare Motivators –

10. TYPES OF FRAUD

11. Your access to healthcare Types of fraud - Providers • 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

12. Your access to healthcare Types of fraud - Subscribers • 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

13. Your access to healthcare Types of fraud- Health Insurance Staff • Registering subscribers in exempt category thereby waiving premium • Fast tracking membership thereby increasing adverse selection • Passing fraudulent claims from providers for kickbacks

14. PREVENTION/MITIGATION

15. Ways to prevent/mitigate abuse

16. 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

17. 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

18. Claims Processing Provider Payment Eligibility & Membership E-vetting & E-adjudication Paper claims CPC CLAIMS SOFTWARE Treatment Protocols G-DRG ICD-10 Statistical Data E-claims

19. Comparing Claims Adjustments at CPC to Nationwide (2013)

20. 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

21. Regional claims data 2012-June 2013

22. WAY FORWARD

23. 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

24. 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

25. 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.

26. THANK YOU