CHALLENGES ACCREDITED HEALTH SERVICE PROVIDERS FACE IN HEALTH INSURANCE CLAIMS MANAGEMENT IN THE BRONGAHAFO REGION

Abstract

This study was conducted to find out the nature and causes of claims management challenges in the Brong-Ahafo Region of Ghana, and to find out what was being done to address those challenges. The study covered three (3) accredited hospitals and 112 respondents. Data for this study comprised both primary and secondary data sources Primary data was collected using questionnaires. Secondary data was derived from annual reports of the service providers and National Health Insurance Scheme claims reports. The research was descriptive and crosssectional in nature. Findings from the study showed that the sheer volume of claims work handled by the facilities has been a major source of challenge to them. Moreover, delayed submission of claims was also identified as a key challenge. Though claim rejection was also identified as a type of challenge, the proportion of claims rejected has gone down significantly. The study results showed that causes of claims management challenges related mainly to increase utilization of provider services as a result of the introduction of the National Health Insurance Scheme, lack of a valid accreditation and contract with the National Health Insurance Authority (NHIA), failure of providers to comply with National Health Insurance Authority documentations and arrangements, and generally weak claims management unit in the provider facilities. The study strongly recommends improvements in claims management activities of health insurance accredited facilities, as well as periodic accreditation and contracting with the NHIA. In addition, the study recommends the strengthening and resourcing of existing facility based claims management units. It is also the recommendation of this study that a course in claims management be introduced in Ghana to train a cadre of health insurance claims professionals as it pertains in other countries.