Health insurance fraud within Nigeria’s National Health Insurance Authority (NHIA)

undermines healthcare sustainability in Benue State’s public hospitals, draining a significant percentage of NHIA funds annually and exacerbating inequities. This study aims to examine the prevalence, patterns, and management strategies of NHIA fraud in selected public hospitals: Benue State University Teaching Hospital, Federal Medical Centre, Makurdi, General Hospital, Gboko, General Hospital, Otukpo, General Hospital, North Bank, and General Hospital, Vandeikya, to inform policy reforms for Universal Health Coverage (UHC).

Grounded in Greed and Grievance Theory, which attributes fraud to socioeconomic pressures, greed, and systemic loopholes, the study adopted a qualitative case study and exploratory design. A purposive sample of 31 participants, including hospital management (three Chief Medical Directors, three Financial Managers, two administration officers), external stakeholders (3 HMO representatives, one EFCC, one forensic investigator, 3 Health management organizations, four police investigation officers), and eight NHIA subscribers, were selected.

Data were collected through semi-structured key informant interviews (KIIs) Thematic analysis, using Braun and Clarke’s framework and NVivo software, revealed five fraud types: falsification of receipts, patient fraud under false identity, billing for unrendered services, ghost patient fraud, and overcharging. These fraudulent activities, fueled by greed and inadequate oversight, elevate out-of-pocket expenses for healthcare services.

Management strategies include robust record-keeping, adequate staffing, and community awareness, limited by digital and funding constraints. These fraudulent activities drain NHIA resources, with annual losses estimated at 30% of funds, exacerbating healthcare inequities and undermining trust in Benue’s public health system.

Recommendations include implementing digital health record systems, strengthening staffing and training, and enhancing community awareness campaigns to deter fraud and optimize resources. The study’s policy relevance lies in guiding NHIA and BNSHIA to strengthen regulatory frameworks, integrate technology, and promote stakeholder accountability, enhancing NHIA efficiency and advancing Nigeria’s UHC goals by 2030.