GOVERNMENT MUST AUDIT ALL NHIMA CLAIMS BEFORE SETTLING THE K1.7 BILLION DEBT.
As Government prepares to settle the K1.7 billion owed under the National Health Insurance Management Authority (NHIMA), I strongly recommend that a comprehensive audit of all claims submitted by healthcare service providers be conducted before any payments are made.
Furthermore, I would advocate for the strict criminal prosecution of anyone found to have deliberately defrauded NHIMA. Those convicted should face imprisonment, where prescribed by law, and be ordered to repay every kwacha fraudulently obtained.
Having personally worked in the insurance industry in the United States, I have serious reservations about the integrity of some of the claims submitted to NHIMA.
My experience with the American healthcare insurance system, particularly Medicare and Medicaid fraud, has taught me that healthcare claims require rigorous verification. Not every invoice submitted represents a legitimate service delivered.
I suspect that a significant proportion of NHIMA claims may contain billing irregularities, inflated charges, duplicate submissions or services that were never provided.
In fact, my working hypothesis is that as many as 50% of submitted claims could contain discrepancies requiring adjustments, while perhaps 10% could involve billing for services never rendered. These are my suspicions, not established findings, and an independent audit would be necessary to determine the actual figures.
MY RECOMMENDATIONS ARE SIMPLE:
1. AUDIT EVERY CLAIM BEFORE PAYMENT. Every invoice must be individually verified against patient records, treatment documentation and services actually delivered.
2. PROSECUTE FRAUD. Any service provider found to have deliberately submitted fraudulent claims should face criminal prosecution and recovery proceedings.
3. NEGOTIATE THE SETTLEMENTS. Once legitimate claims have been established, Government should negotiate discounted settlements with service providers
4. OFFER 50 NGWEE FOR EVERY KWACHA OWED. I would propose an opening settlement offer of 50% of verified outstanding claims, subject to voluntary agreement with providers and the need to protect continuity of healthcare services.
5. STRENGTHEN NHIMA’S INTERNAL CONTROLS. Government must establish stronger claims verification systems, automated fraud detection and continuous auditing to prevent future abuse.
MY POSITION IS CLEAR: GOVERNMENT MUST NOT SIMPLY PAY K1.7 BILLION WITHOUT FIRST ESTABLISHING WHAT IS LEGITIMATELY OWED.
The fact that an invoice has been submitted does not automatically make it a legitimate government liability.
We are dealing with taxpayers’ money, and every kwacha must be accounted for.
If Government can negotiate a 50% settlement across the entire verified K1.7 billion liability, the potential savings would amount to K850 million. Actual savings would depend on audit findings and what providers agree to accept.
This is precisely the kind of fiscal discipline, accountability and expenditure management that Zambia needs.
AUDIT FIRST. VERIFY THE CLAIMS. PROSECUTE FRAUD. NEGOTIATE THE DEBT. THEN PAY.
George N. Mtonga, MBA
Economist & Financial Analyst