The National Health Insurance Scheme (NHIS) is set to deploy an advanced artificial intelligence (AI) system to enhance the audit of claims.

This innovative AI technology aims to identify outliers in real time during claims processing, ensuring greater accuracy and efficiency in the process.

The announcement was made by Deputy Director for Quality Assurance William Omane-Adjekum at a media forum in Kumasi.

Currently, the NHIS boasts a total enrolled membership of about 30 million, with 17.9 million active members and 12 million subscribers with expired memberships.

The scheme is supported by 5,232 facilities and 4 million health service providers.

The NHIA’s claims process has been plagued by numerous issues, including billing for unauthorised services such as outreaches, illegal charges for services and medicines, unbundling of services, non-adherence to the gatekeeper policy, and misapplication of tariffs.

Fraud-related issues have also been prevalent, such as the inflation of the quantity of medicines, insertion of medicines, lack of evidence of attendance, substitution of medicines, and submission of spurious claims.

These problems have resulted in significant quality of care issues, including inappropriate prescription of medicines, substitution of medicines, inadequate documentation and record keeping, inadequate staffing, and inappropriate dispensing of medicines.

In response to these challenges, the NHIS is taking significant steps to deepen stakeholder engagement in clinical audit findings and intensify clinical and compliance audits.

These initiatives, alongside the deployment of AI, are part of the NHIS’s ongoing efforts to improve service delivery and maintain the integrity of the health insurance system.