The Akim Oda Government Hospital in the Eastern Region has been directed to refund a total of three hundred and twelve thousand, four hundred and thirteen cedis, fifty-one pesewas (GH¢312,413.51) to the National Health Insurance Authority (NHIA) following a comprehensive Clinical and Compliance Audit, which uncovered significant irregularities in claims submissions and operational practices at the facility.
The audit, authorized by NHIA Chief Executive Dr. Victor Asare Bampoe, was conducted in response to a whistleblower report that alleged fraudulent activities at the hospital between February and May 2025. Dr. Bampoe emphasized that the investigation was carried out under the provisions of Sections 31(1) and 35(2) of the National Health Insurance Act (Act 852) 2012, granting the Authority the mandate to ensure transparency, accountability, and integrity in the operation of health facilities under the NHIS.
Audit Process and Team Composition
The multidisciplinary audit team, which included personnel from the NHIA Quality Assurance and Internal Audit directorates, representatives from the Claims Processing Center (CPC) in Accra, and an external clinician, conducted the investigation over a period of July 14 to 18, 2025. Their core mandate was to validate the claims submitted by the hospital and assess whether the services billed were genuinely rendered to NHIS members.
The audit focused on both operational compliance and financial integrity, examining documentation, prescription records, and billing practices to identify any deviations from NHIS regulations.
Findings and Recommendations
The NHIA audit uncovered multiple irregularities, including:
- Discrepancies between medicines dispensed and those billed to the NHIS.
- Overbilling of certain pharmaceuticals.
- Inappropriate prescribing practices involving antibiotics, opioids, and anticoagulants.
- Application of incorrect catering-inclusive tariffs, inflating claims.
- Solicitation of out-of-pocket payments from NHIS members for services that should have been covered under the scheme.
As a result of these findings, the NHIA directed the hospital to refund GH¢312,413.51 and recommended stricter validation procedures for future claims. According to the report, “The Authority will not tolerate breaches that undermine public confidence in the National Health Insurance Scheme (NHIS).”
The audit also highlighted misclassification issues, noting that catering-inclusive tariffs were applied throughout the review period despite the hospital being credentialed as a Public Primary Hospital with a catering-exclusive designation, which directly contributed to inflated reimbursement claims.
The report further instructed that:
- The hospital must cease requesting out-of-pocket payments from NHIS members for covered services.
- All subsequent claims, starting from May 2025, must undergo thorough validation before reimbursement.
Scope of Claims and Discrepancies
The Akim Oda Government Hospital, a 162-bed Public Primary Hospital, submitted a total of 120,589 claims between January 2024 and April 2025, totaling GH¢47,645,535.00.
The audit revealed multiple irregularities, including:
- Medicines billed but not dispensed.
- Overbilling of pharmaceuticals.
- Inappropriate prescribing of antibiotics, opioids, and anticoagulants.
- NHIS members being asked to pay out-of-pocket for covered services, a direct violation of NHIS policies.
The audit report emphasized that these discrepancies undermine both patient trust and the financial sustainability of the NHIS.
NHIA Oversight and Commitment to Quality
The NHIA reiterated its commitment to rigorous oversight to ensure access to quality healthcare, improved patient outcomes, and the long-term financial sustainability of the NHIS. The audit forms part of a broader strategy to:
- Ensure compliance with NHIS regulations.
- Safeguard public funds from misuse.
- Protect the rights and benefits of scheme members.
Dr. Bampoe emphasized that the Executive Management of the NHIA remains dedicated to conducting clinical and compliance audits across all health facilities nationwide, aiming to restore public confidence in the NHIS and eliminate exploitative practices such as illegal co-payments and fraudulent claims.
Leadership and Policy Direction
Since assuming office, Dr. Bampoe has underscored the importance of financial controls, accountability, and transparency within the NHIS. As part of his legacy, he has worked closely with the NHIA Executive Management team to curb illegal charges and fraudulent claims, thereby ensuring that NHIS members are not unjustly burdened.
In alignment with President Mahama’s vision to achieve Universal Health Coverage (UHC), Dr. Bampoe stressed the need to remove all financial barriers to healthcare. He highlighted the government’s commitment to timely and frequent release of funds for claims payment, a development made possible through the uncapping of the National Health Insurance Levy (NHIL), which has enabled the NHIA to achieve a debt-free status in claims reimbursement.
Dr. Bampoe further reiterated that all funds under the NHIS must be used exclusively for their intended purpose. Challenges such as co-payments and fraudulent claims are to be strictly eliminated to ensure members receive the full benefits of the scheme.
STORY BY KENNEDY AMPONSAH NTI
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