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Ghana Health Insurance System

Organization: Ghana Ministry of Health

Country: Ghana

Forum: Big data & healthcare

In 2003, Ghana introduced a national health insurance system under which all citizens pay a premium, determined by their income, which entitles them to access healthcare. The government then pays healthcare providers in both the public and private sectors for the services and procedures that they have delivered to subscribers. Unfortunately, the success of the system has been mired by claims fraud, as some providers submit reimbursement claims that are overpriced or that relate to services and procedures that were not carried out.

In an attempt to combat this fraud, the National Health Insurance System (NHIS) has developed a number of data-analysis projects to track suspicious transactions and claim patterns, both before and after payments are made. Pre-payment authentication methods involve inputting the unique member ID number into a database which will:

  • flag any claims under that same ID within the last month at any provider to highlight any patterns or irregularities
  • check the credibility of the given diagnosis against age and gender
  • check that treatment correlates with previous diagnoses
  • check that agreed tariffs for services have been used.

Post-payment methods will look at overall trends within providers and districts to check the volume and value of the most prescribed medicines, service utilization, and to compare costs per claim and monthly value of claims between providers. This will identify any outliers so that further investigations can take place.

This will require an integrated approach, combining data from multiple sources throughout the care pathway. It is hoped that exposing incidences of fraud and rewarding / penalizing providers accordingly, with financial penalties, anti-fraud legislation and early reimbursement incentives for clean claims, will encourage greater compliance in the future and support the system to grow and develop.

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