Statement: RESPONSE TO STATEMENT BY GMA ON THE NHIS The National Health Insurance Authority rejects claims by the Ghana Medical Association (GMA) contained in a communiqué issued at the end of its 3rd National Executive Council Meeting held from 28th May to 31st May 2010 to the effect that the NHIS is collapsing ostensibly due to quality improvement and cost containment measures such as enforcement of the gatekeeper system, prescribing levels and the conduct of clinical audits by the National Health Insurance Authority. The Authority maintains that the greatest threat to the sustainability of the Scheme is the increasing fraudulent practices at some provider and scheme sites. This assertion is supported by the fact that upon carrying out clinical audits into the operations of less than 20% of the NHIS providers, the Authority has been able to recover a huge amount of GH¢7 million in fraudulent claims since the beginning of this year representing claims submitted over the past eighteen months. By far the most serious signal that the scheme is seriously threatened by the sheer magnitude of fraudulent claims, which if not checked could affect the sustainability of the scheme, is the astronomical increases in total claims paid to service providers year on year after discounting factors such as increase in membership and tariffs. In 2009 the Authority paid a colossal amount of GH¢376million in claims to accredited healthcare service providers. This was against GH¢165 million paid in 2008. This means that the Authority paid GH¢211 million more in claims in 2009 than in 2008, an increase of over 200%. In its communiqué issued on Monday, 31st May 2010, the Ghana Medical Association said Clinical Audits by the NHIA “should not be used to cow down facilities that complain about indebtedness of schemes to them”. This begs the question of how the GMA reconciles this stance with the discovery through clinical audits of an amount of GH¢982,188.00 in false claims submitted by five health facilities in the Ketu district after the facilities had in March this year written to the NHIA threatening to withdraw their services if their claims were not paid; or the case of a fictitious claim of GH¢51,000.00 which was credited to the account of Saint Anthony Hospital by the Ketu District Mutual Health Insurance Scheme which again was uncovered through clinical and financial audits. How does the GMA explain the situation where a significant number of NHIS accredited health-care providers do not have staff with the right capacity to handle the processing of their claims and implement appropriate controls that ensure the integrity of claims submitted to the schemes for payment. The Ghana Medical Association should accept the fact that when their members submit fraudulent claims, payment will necessarily be delayed by the need to spend more time vetting them properly. The NHIA appeals to the GMA to join it in arresting the worrying trend of increasing claim malpractices, as revealed by the results of clinical audits conducted by the Authority in recent times. Increasingly, hospitals, clinics and maternity homes are found to have indulged in malpractices such as alteration of diagnoses, irrational prescription of drugs, billing for services not rendered, diagnoses not consistent with treatment, wrongful application of tariffs, all in a bid to increase their incomes through fraudulent means. The NHIA also rejects the suggestion that its officials “have taken the responsibility of micro-managing health facilities and teaching providers how to diagnose and institute treatments for their clients”, as alleged in the GMA statement. The Authority will continue to enforce the prescribing levels of medicines as directed by the Ministry of Health and maintain the gate keeper system in order to ensure quality healthcare delivery. Besides, it will not abandon the on-going clinical audits across the country. Ultimately, patient care is the raison d'être of the NHIS and measures taken by the Authority should not be impugned by suggestions that the interest of the patient is not its prime consideration. The National Health Insurance Authority has not spared the rod on its Scheme staff found to have indulged in fraudulent practices. Over 37 scheme staff members have been sanctioned through outright dismissals, interdictions and other disciplinary action, all with the aim of instilling greater efficiency in the management of the NHIS as demanded by the GMA. The Authority is also collaborating with the law enforcement agencies to apprehend all persons who in any way have perpetrated acts of fraud on the NHIS. Its is worthy of note that members of a syndicate suspected to be issuing false prescription for drugs in order to make claims on NHIS funds have been arraigned before the courts in Accra for prosecution. Far from crippling service providers, as claimed by the GMA, the NHIS is now the financial mainstay of a good number of accredited healthcare service providers in the country. It provides ready sources of funds for the procurement of a significant amount of drugs, medical consumables and other services, as well as being the source of funding for capital projects and logistics and vital equipment for some service providers. The Authority wishes to assure service providers that it is alive to its responsibilities and the debt service schedule is on course. From 1st January to date the Authority has paid a total of GH¢117 million to providers across the country. By the 15th of June, the Authority would have cleared all arrears up to 31st March 2010. Furthermore, by the 31st of July 2010, arrears up to 30th June 2010 would also have been cleared. The collaboration of service providers generally, in the implementation of the NHIS is imperative to the success of delivering an affordable and good quality healthcare to Ghanaians. In that regard, the Ghana Medical Association has a responsibility to support the NHIA in its efforts to eliminate fraud from the NHIS. The situation where over 30 per cent of claims from providers are found to be fraudulent is not acceptable and represents the single most dangerous threat to the sustainability of the NHIS. This must engage the attention of all stakeholders in the healthcare sector. Signed by Nii Anang Adjetey COMMUNICATIONS MANAGER CORPORATE AFFAIRS AND STRATEGIC DIRECTION