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Why NHIS should be monitored by investigative auditors

By Israel Obiora Mbachu

Many African countries have established the national health insurance program. Nigeria’s National Health Insurance Scheme (NHIS) came on stream in 1999. Ghana’s NHIS was established in 2003. Kenya’s National Hospital Insurance Fund (NHIF) has been long operational, since 1966.

The establishment of the national health insurance scheme came about by the desire of the national governments to better serve the health needs of the population. It was hitherto the situation that the citizens have to go before the physician when their condition had become worse because medical costs were not easily affordable. The scheme made it possible for the insured to seek immediate care whenever there is imminent need to see a physician.

However, as in all human endeavours, a miniscule percentage of the participants, particularly physician providers, have resorted to milking the system for pecuniary gains and greed. Every health care or insurance program has been subject to criminal gaming and gaining off the system by physician providers who perpetrate fraud.

Fraud diminishes the objectives of the program, indeed of any human endeavour. If fraud is allowed to fester and not checked, the program will ultimately shut down.

The West, particularly Europe and America, have established fraud task forces either solely by the private sector or by their respective governments in collaboration with the private sector. In the United States, there is the Department of Health and Human Services, which established the Medicare Fraud Strike Force and the Medicaid Fraud Control Units. There are also the Health Care Fraud Unit of the Federal Bureau of Investigation (FBI)and the Centers of Medicare and Medicaid Services (CMS). All the government’s efforts are coordinated under the Department of Justice (DOJ).

There are private organisations such as the Coalition against Insurance Fraud and the National Health Care Anti-Fraud association (NHCAA). These organisations strive to combat health care fraud and safeguard the US annual health care expenditure of over US$3 trillion. In spite of their efforts, however, they acknowledge that about 5% of the annual expenses is lost to fraud. The FBI estimates that over US$250 billion was lost to fraud in 2014. The efforts of the US Department of Justice (DOJ) in investigating health care fraud have however resulted in recoveries of the sum of US$5.7 billion in 2014 and US$3.3 billion in 2015. From 1997 to 2015, it has recovered the sum of US$27.8 billion.

The Canadian Health Care Anti-Fraud Association (CHCAA) reports that out of C$120 billion spent by Canada annually on health care, fraud loss is over C$12 billion per year.

European countries have not fared any better in effectively checking fraud in their respective health care programs. The 2020 Health in the United Kingdom estimates that the true cost of fraud in the UK’s National Health Services (NHS) is over  £3 billion per year.

It has been recognised that the various ways the physicians bill the programs include billing for services not rendered, unnecessary tests in order to collect insurance payments and use of another’s insurance card.

African countries’ experience including Nigeria’s with respect to fraud cannot be different from the experience of the West. While discussing this topic with some people in Nigeria, one of the interviewees, an employee of a multi-national corporation, covered under the NHIS informed me that his wife took ill at a time and went to the hospital. She was billed ¦ 61,000.00. However, her cover under the scheme was limited to ¦ 50,000.00 per outpatient visit, which meant that she has to pay ¦ 11,000.00 from her pocket. He had reached into his trouser pocket to retrieve his wallet when one of the physicians advised him that nobody pays cash from their pocket. He was told to present his insurance card and they will apply it to his wife! That is fraud and an indication it thrives in the system.

“The challenge in the use of recent medical graduates as fraud Investigators is that although they may be versed in medical practice, they lack fraud knowledge and training.”

Another indication that led me to the suspicion that fraud exists within the NHIS in Nigeria, is that over 60% of health insurance fraud perpetrated in Nigeria against foreign public and private insurers involves physicians colluding with the subscribers/policyholders. More than 60% of these physicians are enrolled in the NHIS network as expressed in their letterhead. If they are billing or attempting to defraud overseas companies, then the local programs cannot be different.

If fraud is occurring under Nigeria’s NHIS so it is in most African countries health care schemes. Kenya recognizes this fact in their National Hospital Insurance Fund (NHIF). As a result, it encourages whistleblowers to report fraud and has a hotline or tip line on their web site. For Nigeria, I’m aware that although they have not instituted an Internet hotline, but the HMOs deploy young physicians as Investigators to investigate suspicious claims.

In order to solve these challenges, not only in Nigeria but around the world, I have developed a program to train HMO Investigative Auditors. This will be the first of such a program anywhere in the world.

The HMO Investigative Auditor will be able to investigate and audit both local HMO claims as well as foreign claims. Investigation entails that the trained professional can effectively undertake the investigation of one or more suspicious claim in order to determine the facts about it. Auditing requires that occasionally, claims from every primary, secondary and tertiary-level hospital in the network should be audited to determine if fraud is being perpetrated and, if so, to what extent.

Additionally, the HMO Investigative Auditor can effectively investigate foreign health claims including travel insurance (medical expenses) claims and report factually to the principals.

“The Nigerian HMO Investigative Auditor will be able to effectively investigate local and foreign HMO claims. He may choose to work only cases in Nigeria or within ECOWAS or even around the world.”



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