Abstract:
In 2004, Ghana started implementing a National Health
Insurance Scheme (NHIS) to remove cost as a barrier
to quality healthcare. Providers were initially paid by
fee – for - service. In May 2008, this changed to paying
providers by a combination of Ghana - Diagnostic Related
Groupings (G-DRGs) for services and fee – for -
service for medicines through the claims process.
Objective: The study evaluated the claims management
processes for two District MHIS in the Upper
East Region of Ghana.
Methods: Retrospective review of secondary claims
data (2008) and a prospective observation of claims
management (2009) were undertaken. Qualitative and
quantitative approaches were used for primary data
collection using interview guides and checklists. The
reimbursements rates and value of rejected claims were
calculated and compared for both districts using the z
test. The null hypothesis was that no differences existed
in parameters measured.
Findings: Claims processes in both districts were similar
and predominantly manual. There were administrative
capacity, technical, human resource and working
environment challenges contributing to delays in
claims submission by providers and vetting and payment
by schemes. Both Schemes rejected less than 1%
of all claims submitted. Significant differences were
observed between the Total Reimbursement Rates
(TRR) and the Total Timely Reimbursement Rates
(TTRR) for both schemes. For TRR, 89% and 86%
were recorded for Kassena Nankana and Builsa
Schemes respectively while for TTRR, 45% and 28%
were recorded respectively.
Conclusion: Ghana’s NHIS needs to reform its provider
payment and claims submission and processing systems
to ensure simpler and faster processes. Computerization
and investment to improve the capacity to administer
for both purchasers and providers will be key
in any reform.