National Health Insurance Claim S M Anagem Ent: A Case Study Of Tw O Districts In The Upper East Region

ABSTRACT Background In 2005, Ghana started implementing a National Health Insurance Scheme with the aim o f removing cost as a barrier to accessing healthcare. The Scheme had as an important component, the Claims Process through which services rendered by providers could be reimbursed by the Scheme. Right from its inception, the Claims Process has been dogged with challenges: from lack o f compliance by providers and Scheme M anagers with the original tariff structure developed to outstanding reimbursements to many facilities. In the 2008 Ghana health sector review, health facilities nationwide were owed a total of GH049 m illion m ost o f it in unpaid claims. Additionally, a new tariff system using Diagnostic Related Groupings (DRGs) was introduced in M ay 2008. Objective The study thus had the general objective o f assessing the claims management process for the Kassena Nankana and Builsa District Mutual Health Insurance Schemes in the Upper East Region o f Ghana. Methods It employed a combination o f retrospective review of secondary claims data (2008) and a prospective observation o f actual claims management for the year 2009. A mixture o f qualitative and quantitative approaches was employed using appropriate interview guides and checklists. Qualitative data collected was analyzed according to themes. Quantitatively, proportions o f the claims rejection including costs was calculated for both districts plus the reimbursement rates. The various proportions calculated for both districts were then compared using the z test for testing difference between two population proportions. This was done under the null hypothesis that no differences existed between Kassena Nankana and Builsa Districts. All methods were analyzed together for complem entary effect. Findings The claims processes in both districts were sim ilar with similar technical, human resource, working environm ent and financial challenges. Also, both Schemes rejected less than 1% o f all claim s submitted from the district hospitals in 2008. Significant differences were observed between the Total Reim bursem ent Rates (TRR) and the Total Timely Reim bursem ent Rates (TTRR) for both schemes. For TRR, 89% and 86% were recorded for K assena Nankana and Builsa Schemes respectively while for TTRR, 45% and 28% were recorded respectively. Conclusion Delay in claims reimbursement is a major challenge that can cripple efficient health service delivery.