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Most HNIS Service Providers don’t understand claims processing – NHIA Director

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It has emerged that most Service Providers of the National Health Insurance Scheme (NHIS) do not have adequate knowledge in applying the NHIS Tariffs, Medicine List and General Claims Processing.

Upper East Regional Director of the National Health Insurance Authority (NHIA), Sebastian Alegpulinsa, disclosed this at the War Memorial Hospital in Navrongo in the Upper East Region when his outfit organized a two-day capacity building training for Health Service Providers in the region.

Being the first of its kind since 2008, the training is aimed at equipping service providers especially the billers on the Out-Patient Department (OPD) and In-Patient tariffs procedures and guidelines to avoid incidents of wrong selection or misapplication of tariffs, providing relevant know-how on Claims Management, General Application of the National Health Insurance Tariffs and Medicine List.

Mr. Alagpulinsa also said the prescribers will also be equipped with the medicines list and procedures of matching diagnosis with treatment in a manner to avoid clinical and compliance audit deductions on providers’ claims. Again, the training is expected to resolve the challenge of documentation of patients’ information and general patients’ folder management while enhancing the financial position of providers and quality healthcare delivery to NHIS members.

The director said: “The critical issue at stake is that most of our service providers are having a difficulty in applying the NHIS Tariffs and the medicines list properly as well as general claims processing. This in effect is affecting the quality of their claims as well as service delivery to Subscribers. These processes in most cases result in financial losses to the providers and sometimes also to the scheme which is further creating financial sustainability challenges to both partners.”

Mr. Alagpulinsa disclosed that all district hospitals in the region are billed for this training; including service providers in the private sector.

According to him, the NHIA has the responsibility of giving quality health care to Ghanaians by providing financial risk protection. “This simply means that when people are receiving health care, they should not pay any money out of their pockets.” he explained.

The regional director revealed that in the last Clinical and Compliance Audit, an amount of Gh₵ 500,000 was deducted from claims submitted by War Memorial Hospital. As a result, he observed that there are series of deductions going on in the various hospitals in the region and called for a paradigm shift.

“What I have realised across the region is that there is a need for this sort of change. Why because providers generally have a very weak understanding of the tariffs structure and the application of the medicines list, in that, if you don’t get this right, the issues that are in the clinical audit report will continue to reoccur.” He admonished.

Mr. Alagpulinsa, called for a collaborative effort from partners to realise a reduced or possible extinction of Clinical and Compliance Audit Deductions on Providers’ claims which adversely leave their facilities with very little resources to operate.

For his part, Isaac Akonde the Director for Claims Processing Center (CPC) – Tamale, revealed that the NHIA is mandated under a legal framework to pay only legitimate claims, hence, the need for the capacity building training. “If we have to get legitimate claims, it will start from the very point a patient enters the Facility until the point the patience exits the facility. At each of the stages in the hospital, every staff has a responsibility to play to ensure that at the end of the day, we have a claim that is legitimate for the authority to pay.” He emphasised.

Some participants, who interacted with The Chronicle, said the training was an eye-opener to them. “This exercise is timely. It will help arrest our weak understanding of the tariffs structure.” “A lot more of our colleagues need to be part of this beneficial programme.” Osman and Gifty shared respectively.

Source: TheChronicle.com.gh|Ghana

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