NATURE AND FORMS OF FRAUDS, ABUSES AND WASTES (FAWS) IN HEALTHCARE

Nature and Forms of Frauds, Abusesand Wastes (FAWs) inHealthcare

Introduction

Health system in Nigeria has witnessed persistent service delivery challenges and failures that have resulted in sub optimal and relatively poor health outcomes compared with other low income countries. 

Worldwide, governments face pressure to provide health services effectively, efficiently and equitably through multidimensional approaches which often converge in emphasizing accountability as a core element in implementing health reforms aimed at improving health system performance.

Accountability is the obligation of individuals or agencies to provide information about, and/or justification for, their actions to other actors, along with the imposition of sanctions for failure to comply and/or to engage in appropriate action.

It involves measures to ensure that the person or organization with the authority to provide a service actually delivers that service i.e. that providers and policy-makers are answerable for their actions, and to demonstrate that they have delivered.

The accountability actors include the health ministries, finance ministries, legislatures, regulatory agencies, insurance agencies, public and private providers, facility management and boards, and the service users (clients) etc. 

They are all connected to each other in networks of control, oversight, cooperation and partnership and reporting.However, the accountability interests of these actors vary. 

Accountability is often exercised in three aspects:

1. Financial accountability. This area deals with financial control and management, and involves compliance with laws, rules and regulations.
2. Performance Accountability. This deals with performance measurement and evaluation, and service delivery improvement.

• Political/democratic accountability. This deals with the relationship between the state and the citizen, and discussions on equity issues, responsiveness and trust building.

Failed or insufficient accountability furnishes abuses, non-compliance with ethics, procedures and standards and leads to poor performance. 

There are numerous testimonies of unattended and unresolved cases of abuses, frauds and wastes; and non-compliance with professional ethics, procedures and standards. The unfortunate reality is that failed accountability is a problem in Nigeria health sector and the health system is largely unaccountable.

Nature and Forms of Abuses, Frauds and Wastes

The nature and forms of Frauds, Abuses and Wastes (illegal, inappropriate acts and behavior)vary from one form to another, and frequently occur in three categories covering infractions in Health Development Projects, Health and Medical Service Delivery and Provider Prepayment System.

Infractions in Health Development Projects.

Examples under this category include;

1. Mismanagement of Contracting Process: At all levels, construction of infrastructure including boreholes and supplies are often characterized by contract process manipulation including contract splitting, kickbacks, over-invoicing and overpayment for supplies.
2. Abandonment of (Uncompleted) Contract:This refers to Partial or incomplete execution and abandonment, sometimes payment is made in excess of the work done. There are many health projects initiated at all levels that have been abandoned, often after initial payment.

• Abandonment of Supplied/Donated Items:This refers to abandonment of equipment at the medical stores and sea ports and under unfavorable conditions leading to deprivation of use by those in need and huge waste.

1. None Compliance with Specification: Use of substandard construction materials, supply of substandard equipment and supplies/commodities have been reported and investigated in the past.
2. Virement of Projects: There are instances where projects approved in the appropriation are substituted at the point of execution.
3. Conversion of Public Project:There are reported cases where public financed projects are converted into personal/private projects.

• Diversion of Projects: It involves change of delivery points and commonly affect ambulances, equipment and supplies, without due diligence. 
• Replication of Projects: Repetition of projects year in/out.

1. False Negotiation Cases: these are cases that arise from situation in which a health care provider makes false statements to induce the government to enter into a contract for services or supplies that are not required.

Health and Medical Service Delivery

1. Absenteeism: Absenteeism poses a serious challenge to health care delivery and can severely limit patient access to services, reduce quality and patients satisfaction.
2. Self-referral:referring the patients to a clinic, diagnostic service, hospital etc. with which the referring physician has a financial relationship and the referred-to party pays a commission back to the physician.

• Unofficial payment: Informal charging by providers is common and often have serious equity implications.

1. Providing unnecessary care and maximizing care:It may also happen that more healthcare is provided than was actually needed to heal the patient and sometimes certificates are falsified to show the medical necessity of certain actions in order to justify payments.
2. Purchasing Public Positions: The commercialization of public positions involves the practices of selling public positions and requiring bribes for promotion. It fundamentally undermines good performance.
3. Substitution of supplies and goods: There are instances where goods and supplies are substituted after delivery by the providers.

• Pilfering of Supplies: Petty theft of equipment, pharmaceuticals and supplies.
• Drug Management and Leakage: Drugs tend to be a commonly “leaked” product given that it can fetch a higher price in the private market.  There is rampant stealing of public sector drugs and the resale in the private market.

1. Data, records and reports manipulation: Falsification of data, records and reports:  population records, immunization records, FP records, ANC/Delivery records, presence of health workers, and communities and households visitations is not uncommon.
2. Wastage of Drugs and Commodities: Procurement of near expiration (short-shelf-life) pharmaceutical products leads to wastages. The ARVs, FP commodities, Anti-malarial and many pharmaceutical products are commonly affected.
3. Diversion of operational vehicles: Diversion of vehicles for unofficial use - ambulances and Hilux etc.

• Lack of Basic Equipment: Basic Equipment required for routine service delivery such as BP machine, stethoscope and weighing scales are often lacking.
• Equipment Failure: Lack of preventive maintenance of basic and critical equipment has often led equipment failure. Solar refrigerators and Radiotherapy machines are common examples.
• Poor Performance: There is general poor performance in service outcomes - RI Coverage, Contraceptive Prevalence, SBA, etc.

1. Conflict of Interest: Spending official governmenttime in private practice and diversion of patients etc.

• Leakage of Operational Funds: Operational resources for staff and other inputs often do not reach the front line -- the clinics and hospitals that deliver the services to the population, and this is critical to a functioning health system
• Prescription of specific brands of medicine:pharmacists can fill a prescription with a specific brand of medicines instead of another that yields a bonus from the pharmaceutical company, beyond financial implications; this might also be detrimental to the patient’s health. Physicians themselves can fraudulently write prescriptions for money.
• Off-label promotion of drugs: thisinvolves the marketing of drugs for uses which are not approved by the Food and Drug Administration.

Provider Prepayment System.

1. Waiving co-payments:Insurance plans can require co-payments for certain services to incentivize patients to make appropriate cost-minded decisions in their health care; health care providers waiving co-payments or deductibles, removing these incentives and violating their participation agreement with the insurer.
2. Lying about eligibility:Patients can lie about their situation when they visit a pharmacist/physician or misrepresent information about their dependents to get insurance coverage for them for example claim exemption from prescription charges, when they are not exempt.

• Improper coding and upcoming:Improper coding, sometimes called upcoding is the billing for a more expensive service or procedure than the one performed, it could be as a result of administrative error versus a malicious attempt to increase revenue.

1. Unbundling:Unbundling means creating separate claims for services or supplies that should be grouped together, today software such as Grouper looks for unbundling and will either reject unbundled claims or “re-bundle” the claims and adjust the bill to pay for the combined procedure code.
2. Submitting double bills:care providers can try to submit the same claim multiple times, in order to get paid two times for performing one action. Billing multiple times for the same service, Automatic acceptance of claims is mostly done to improve processing speed, however for true efficiency not only speed matters. Tests for legitimacy are just as important.
3. Billing for services not provided:claims are submitted for health care services that have not been provided or for medicines or medical devices that have not been delivered to the patient.

• Device and services price manipulation:usually at a small, regional scale, providers of medical equipment or health services can manipulate prices for certain groups of clients, if they know Medicaid will pay varying rates for services, the may increases prices directly. Or, they may move across the street to the next zip code from which they can bill a higher rate.
• Billing for services rendered by unqualified personnel:Care can be provided by people who do not have the credentials or license to actually perform that kind of care, e.g. an intern providing care that a physician bills for and which the intern is uncertified to perform or unqualified to bill.

1. Identity theft: Identity fraud may happen where an uninsured individual assumes the identity of a person with insurance coverages to obtain services or to hide a certain illness.
2. Doctor shopping:If feigning pain or bribing a doctor does not work, a drug-seeking person may simply look for another doctor who will provide the desired prescriptions. A patient can easily visit multiple doctors to obtain prescriptions.
3. Reverse false claim cases: False claims that are paid by an insurance program result in a provider receiving money from the insurer. Reverse false claims represent situations where a care provider owes money to the government and doesn’t pay it back on time.

Combatting Abuses, Frauds and Wastes in Health

Healthcare systems are under attack by dishonest people who exploit its programs, howevercombating fraud, waste and abuse in health care remains a popular reference for reducing healthcare cost and expenditures on healthcare.

In order to improve efficiency in the health system, eliminatingfrauds, abuses and wastes, should be one of the top priorities in health care reform.

The National Health Act (2014) contains provisions relating to frauds, abuses and wastes aimed aiding the federal government in mitigating unresolved cases of abuses, frauds and waste; and non-compliance with professional ethics, procedures and standards.

However, there are still challenges in area of implementation and therefore the need for developing effective compliance programs in healthcare institutions and facilities e.g. quality assurance programs, the purpose of this is to promote the prevention of criminal conduct, enforce government rules and regulations, while providing quality care to patients.

The Role of Initiative for Health Accountability and Transparency (IHAT)

IHAT is a Non-Governmental not-for Profit Organization founded to promote and monitor accountability in the health system in Nigeria. 

Our Mission: To Make Accountability A Core Element Of    Healthcare. 

The Strategic Objectives

IHAT three strategic objectives: 

1. To expose using available scientific based evidence, how failed accountability in health has undermined service delivery and health system performance.
2. To promote stronger accountability linkage among the citizens, policy makers and service providers
3. To be a catalyst – fulfilling our mission of making accountability a core element of the health system.

At IHAT, Our Programmatic Focusincludes the following: 

1. Networking with Stakeholders in Governance (Legal and Policy) Matters towards improving accountability in health system
2. Advocacy and Sensitization Meetings, Workshops & Conferences  to draw leadership and management attention and public spotlight

• Programme Communication through Public Enlightenment Campaigns - Radio/TV and IEC materials

1. Quality Assurance including the Promotion and Protection of Consumer (Patients) Rights 
2. Monitoring, Surveillance and Evaluation Activities - Health Budgets, Programs/Projects and Service Delivery
3. Complaints Investigation and Reporting. 

• Use of Electronic Platforms – Tracker and Dashboard, and Feedback (Complaints) App.
• Information Analytics and Research 

1. Consultancy Services as Independent Observers.

Are you passionate for, and interested in the promotion of Right to Good Health? 

Why not partner with IHAT as we work to improve health care in Nigeria. 

Miss Monica Oche(08072338232

Initiative for Health Accountability and Transparency