Double payment for medical services, hourly rental of equipment and lack of licenses: results of the state audit of the compulsory social health insurance system
The results of the state performance audit of the Social Health Insurance Fund NJSC and its regional branches for 2022-2023 were considered at a meeting headed by the Chairman of the Supreme Audit Chamber of the Republic of Kazakhstan Alikhan Smailov.
According to Rassul Rakhimov, the Member of the Supreme Audit Chamber, the second audit in this area covered funds and assets worth 3.8 trillion tenge. The audit activities affected 13 organizations.
Today, the compulsory social health insurance (OSHI) system includes 16.2 million people. At the same time, 12 million belong to preferential categories, contributions for which are made by the state. In addition, there are about 2 million civil servants, employees of budgetary organizations and the quasi-public sector. As a result, the financial burden on the state, excluding private expenses (paid medicine), is at least 76%. In this regard, one of the key conclusions of the audit is that, despite the introduction of OSHI, there is still no tangible reduction in the burden on the state due to the joint responsibility of citizens.
There is a chronic underutilization of the National Fund's assets. During the audited period, over 50 billion tenge was allocated as part of guaranteed and targeted transfers. However, 13 billion tenge, or 26%, remained unused.
The Fund does not pay due attention to monitoring the quality of medical services. For example, in Astana, a control inspection of the two largest suppliers within the framework of OSHI was carried out, to which a total of 179 thousand people were assigned. As a result, the lack of own production premises and medical equipment was revealed, and the practice of renting them by the hour was observed. A number of clinics of these LLPs did not have licenses for certain types of activities and ramps for receiving immobile citizens.
Along with this, the audit revealed facts of double payment by co-providers for medical services at the expense of the Social Health Insurance Fund (SHIF) and the citizens themselves, although according to the existing rules, medical institutions undertake the obligation to not accept payment for those types of medical care that are financed through the Guaranteed Volume of Free Medical Care and OSHI. Thus, for inpatient care, facts of double payment by at least 1.7 billion tenge were revealed, for outpatient care - by 27.6 billion tenge. However, this aspect is not monitored by the fund.
A separate violation was the double payment by the SHIF for dental clinic services. The medical insurance tariff already included the cost of anesthesia, but dentists took an additional payment for it from the fund for a total of 2.1 billion tenge.
In addition, as a result of reconciliation of data from the information systems of the Ministry of Health, the Ministry of Internal Affairs and the Ministry of Justice, facts of registration of medicines for citizens who left for permanent residence abroad were revealed.
During the meeting, Alikhan Smailov emphasized that the SHIF is obliged to ensure high-quality monitoring and control of the targeted use of budget funds.
“And this should not be done manually, but automated. The fund must have its own risk management system, on the basis of which it is necessary to monitor and control the quality of services provided, the availability of a production base, equipment, relevant medical licenses and permits,” said the Chairman of the Supreme Audit Chamber.
The state audit also revealed that as of March of this year, 109 medical organizations in Kazakhstan had overdue accounts payable of 19 billion tenge. However, when distributing SHIF funds, the financial situation of providers is not taken into account, which may negatively affect the provision of medical services to the population.
In general, the results of the audit established:
- procedural violations amounting to more than 32 billion tenge;
- ineffective planning and use of funds - by 31.1 billion tenge.
The amount of financial losses and lost profits amounted to 11.8 million tenge. 65 procedural violations, 154 other violations and systemic deficiencies were also identified.
Materials on facts of double payment for medical services and registrations are transferred to law enforcement agencies.
The meeting was attended by the Minister of Health Akmaral Alnazarova, the Chairman of the Board of the SHIF Abylkair Skakov, as well as responsible officials of interested government agencies.