Abstract:
The National Health Insurance Scheme is bedevilled with lots of problems. One
of such problems is payment of persistent and ever-increasing healthcare claims.
This phenomenon, if not properly controlled, may have the futuristic propensity to
hamper the smooth running of Takoradi Mutual Health Insurance scheme
(TMHIS) in particular and health insurance schemes in the country in general.
The main aim of this study was to assess stakeholders’ perception on healthcare
claims fraud control at Takoradi Mutual Health Insurance Scheme. The study
used the correlational study design. A total of 150 respondents made up of staff of
TMHS, staff of service providers of TMHIS and staff of the National Health
Insurance Authority were interviewed. The main research instrument used to
collect data for the study was the questionnaire. Descriptive and inferential
statistics such as mean, standard deviation and standard regression were used to
analyse the data. The findings of the study show that internal control and
communication of claims payment policies did not significantly influence claims
fraud. The study, however, found that human resource challenges, compliance
with claims payment policies and management oversight responsibilities
significantly affected claims fraud control at TMHIS.It was therefore,
recommended that TMHIS conduct regular claims verification at provider sites
and at the scheme level to rectify any possible claims related anomaly.
Furthermore, qualified, adequate and well-motivated staff should be employed to
handle claims. Finally, claims should be paid fairly and promptly to avoid
manipulation of claims and claims officers by healthcare providers.
