Assessing stakeholders’ perception on healthcare claims fraud control at Takoradi Mutual Health Insurance Scheme

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.