The National Health Insurance Authority (NHIA) is planning to establish an Anti-Fraud and Illegal Payments Directorate to tackle unauthorised charges imposed on patients by healthcare providers under the National Health Insurance Scheme (NHIS).
The proposed directorate is expected to strengthen the Authority’s ability to detect fraudulent activities, investigate illegal out-of-pocket payments and curb irregularities in claims submitted by healthcare facilities.
The initiative forms part of broader efforts to protect NHIS members from unauthorised charges and improve the financial sustainability of the national health insurance programme.
The NHIA is also calling on Parliament to prioritise amendments to the National Health Insurance Authority Act, 2012 (Act 852), to strengthen sanctions against individuals and institutions found culpable of fraud and illegal payments under the scheme.
The Authority’s Deputy Chief Executive Officer in charge of Operations, Dr Kwesi Djokoto, made the appeal during a visit by Parliament’s Health Committee to the NHIA.
Dr Djokoto said stronger legislation and enforcement mechanisms were needed to complement the Authority’s digital systems and operational reforms designed to improve claims processing, payments and the monitoring of healthcare providers.
He explained that the NHIA had invested in digital infrastructure to improve its operations but required additional legislative support to effectively address fraud and unauthorised charges.
“We have super digital infrastructure in place that would support our operations, so the committee can help us prioritise the amendment of Act 852. The Ministry of Health is already working on it,” he said.
According to Dr Djokoto, the proposed amendments would strengthen sanctions for fraud and illegal payments while supporting funding for capital expenditure in the 2027 financial year.
He also highlighted improvements in the Authority’s claims management and payment systems, noting that claims were processed electronically, with a 20-day turnaround time, while payments were being made monthly.
“In summary, claims are electronic, with a 20-day turnaround time; we are paying monthly, and we have digital interventions to enhance the work of the National Health Insurance Authority,” he said.
The planned directorate is expected to help address practices in which NHIS members are charged directly for services or items that should be covered by the scheme, subject to the applicable benefit package and rules.
Illegal charges have the potential to undermine public confidence in the NHIS by imposing additional financial burdens on beneficiaries who rely on the scheme to access healthcare.
The NHIA’s proposed enforcement measures are therefore intended to improve accountability among healthcare providers, strengthen compliance with the scheme’s requirements and protect members’ access to covered services.
The Authority believes that combining digital monitoring systems with stronger legal provisions will improve its ability to identify irregularities, deter fraudulent practices and ensure that public resources allocated to the NHIS are used appropriately.