A Clinical and Compliance Audit report has directed the Akim Oda Government Hospital in the Eastern Region to refund an amount of GH¢312, 413.51 received as claims reimbursed to the National Health Insurance Authority following findings of malpractices in its operations and claims submissions.

The audit, sanctioned by NHIA Chief Executive Dr. Victor Asare Bampoe, was conducted in response to a whistleblower report alleging fraudulent practices at the facility between February and May 2025.

Dr. Bampoe called for the audit in accordance with Sections 31(1) and 35(2) of the National Health Insurance Act (Act 852).

The multidisciplinary audit team, comprising personnel from NHIA’s Quality Assurance and Internal Audit directorates, Claims Processing Center (CPC) Accra, and an external clinician, conducted the investigation from July 14 to 18, 2025.

Their mandate was to validate claims submitted by the hospital and assess the actual services rendered to the National Health Insurance Scheme (NHIS) members.

Discovery and Recommendations

The NHIA audit uncovered multiple irregularities in claims submitted for reimbursement.

These included discrepancies between medicines dispensed and those billed, overbilling of certain drugs, and inappropriate prescribing practices involving antibiotics, opioids, and anticoagulants.

The hospital also applied incorrect catering-inclusive tariffs and demanded out-of-pocket payments from NHIS members for services that should have been covered. As a result, the NHIA has recommended a refund of GH₵312, 413.51 to the Authority and called for stricter validation of future claims.

According to the report, “The Authority will not tolerate breaches that undermine public confidence in the National Health Insurance Scheme (NHIS)."

“The facility is hereby directed to refund GH¢312, 413.51 to the NHIA for various breaches and irregularities identified in claims submitted,” the sanctioned report stated.

The audit also found 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.

This misclassification contributed to inflated claims. In light of these findings, the report has recommended that, in addition to the refund, “The facility must desist from asking active NHIS members to make out-of-pocket payments for services covered by the Scheme.

Subsequent claims, starting from May 2025, should be thoroughly validated before reimbursement,” the report directed.

More facts

The Akim Oda Government Hospital, credentialed as a Public Primary Hospital (Catering Exclusive) with a 162-bed capacity, submitted a total of 120,589 claims over a 16-month period from January 2024 to April 2025.

These claims amounted to GH¢47,645,535.00. However, the audit revealed multiple discrepancies, including medicines billed to the Scheme but not dispensed, overbilling of pharmaceuticals, and inappropriate prescribing of antibiotics, opioids, and anticoagulants.

The report stated, “There were variances in the quantities of medicines dispensed in the facility’s system and those submitted to NHIA for reimbursement.”

It further noted that “members of the scheme make out-of-pocket payments for some services and medicines covered by the scheme,” a direct violation of NHIS policy.

The NHIA has pledged to continue its oversight efforts to improve access to quality healthcare, enhance patient outcomes, and maintain the financial sustainability of the Scheme.

The NHIA indicated that the audit forms part of its broader commitment to protect the financial sustainability of the Scheme, ensure compliance with regulations, and guarantee quality healthcare delivery.

“The audit identified non-compliance with regulations and directives. Appropriate recommendations have been made to improve the NHIS and to ensure the financial sustainability of the Scheme,” the report concluded.

The Executive Management of the Authority has reiterated its commitment to continuing clinical and compliance audits across health facilities nationwide to safeguard the integrity of the NHIS and ensure that members receive the full benefits of the scheme without exploitation.

Since assuming office, Dr. Bampoe has emphasised the importance of financial controls, accountability, and transparency in the administration of the NHIS, to safeguard the integrity of the Scheme and ensure that public funds are used appropriately.

As part of his intended legacy, he, with support from his Executive Management team, has resolved to curb illegal charges and fraudulent claims under the NHIS as part of efforts to rebuild public confidence in the Scheme.

He has been soliciting the opinions and support of all stakeholders, particularly staff and service providers, in his effort to curb the illegality of NHIS members being charged out of pocket for services paid for by the Scheme, often referred to as co-payment.”

Dr. Bampoe has also emphasised that, in line with President Mahama’s vision to achieve Universal Health Coverage (UHC) as soon as possible, all financial barriers to healthcare must be removed.

He has noted that the government has remained committed to releasing funds for claims payment on a frequent and timely basis.

This, he noted, is demonstrated by the NHIA’s recent debt-free status on claims, made possible through the government’s frequent release of funds to the Authority, a development facilitated by the uncapping of the National Health Insurance Levy (NHIL).

He stressed that the initiative is aimed at rebuilding public confidence in the Scheme, emphasising that the funds must always be used for their intended purpose.

He therefore urged that challenges such as ‘co-payments’ and fraudulent claims must be eliminated at all costs.