Kasim Hajara Adamu, Suleiman Auwal Garba, Saulawa Fahad Abubakar, Usman Suleiman, Aliyu Muhammad, Aminu Nazifi Sani
The MBBS Training Programme, College of Medical Sciences, Ahmadu Bello University Zaria, Kaduna State, Nigeria.
Department of Community Medicine, College of Medical Sciences, Ahmadu Bello University Zaria, Kaduna State, Nigeria.
Niger Med J. 2025 Apr 3;66(1):256-265. doi: 10.71480/nmj.v66i1.700. eCollection 2025 Jan-Feb.
Fraud in healthcare is an immense challenge that poses a direct threat to sustainable healthcare financing across low and high-income countries. Enrollee health insurance fraud is a relatively understudied form of fraud that thrives in settings characterized by weak and fragmented healthcare systems. This study examined the knowledge and perception of enrollee health insurance fraud among healthcare workers at a tertiary hospital in Kaduna State, North-western Nigeria.
Using a stratified sampling technique, 232 healthcare workers were interviewed using a structured, self-administered questionnaire that was developed for the study. Data on knowledge and perception of enrollee fraud was obtained and analysed using IBM SPSS Statistics. The data was presented using frequency distribution tables, while figures were drawn using Microsoft Excel.
The majority of the respondents were clinical staff, including medical doctors (29.7%), nurses (31.5%) and health assistants (14.2%). A total of170 (73.3%) respondents were aware of enrollee fraud and up to 113 (66.5%) encountered at least one case of enrollee fraud. The most common types of enrollee fraud identified by the respondents were impersonation (67.7%) and faking symptoms (57.1%). Respondents recognised adverse consequences of enrollee fraud, including depletion of resources (74.1%), blocking eligible patients from accessing care (73.6%), and exhaustion of healthcare workers (61.8%). A total of 111 (65.3%) agreed that enrollee fraud is common in the hospital and despite a high level of awareness, only 72 (42.3%) agreed that they are adequately informed about enrollee fraud.
There was a high level of awareness of enrollee fraud among the respondents with a good perception of its manifestations and implications on healthcare delivery. It is recommended that immediate steps be taken to educate healthcare workers and enhance their capacity to detect and deter enrollee fraud while investing in longterm strategic measures and technology-based solutions.
医疗保健领域的欺诈行为是一项巨大挑战，对低收入和高收入国家的可持续医疗融资构成直接威胁。参保人医疗保险欺诈是一种相对较少受到研究的欺诈形式，在医疗体系薄弱且分散的环境中盛行。本研究调查了尼日利亚西北部卡杜纳州一家三级医院的医护人员对参保人医疗保险欺诈的认知和看法。
采用分层抽样技术，使用为该研究开发的结构化自填式问卷对232名医护人员进行了访谈。获取了有关参保人欺诈的认知和看法的数据，并使用IBM SPSS Statistics进行分析。数据使用频率分布表呈现，图表使用Microsoft Excel绘制。
大多数受访者为临床工作人员，包括医生（29.7%）、护士（31.5%）和健康助理（14.2%）。共有170名（73.3%）受访者知晓参保人欺诈，多达113名（66.5%）受访者至少遇到过一例参保人欺诈案件。受访者识别出的最常见的参保人欺诈类型是冒名顶替（67.7%）和伪造症状（57.1%）。受访者认识到参保人欺诈的不良后果，包括资源耗尽（74.1%）、阻止符合条件的患者获得护理（73.6%）以及医护人员疲惫不堪（61.8%）。共有111名（65.3%）受访者认为参保人欺诈在医院很常见，尽管知晓程度较高，但只有72名（42.3%）受访者认为他们得到了关于参保人欺诈的充分信息。
受访者对参保人欺诈的知晓程度较高，对其表现形式以及对医疗服务的影响有较好的认知。建议立即采取措施对医护人员进行教育，提高他们发现和阻止参保人欺诈的能力，同时投资于长期战略措施和基于技术的解决方案。
