The National Health Insurance Scheme (NHIS) Claims Processing Center (CPC) in Tamale has saved the country a substantial amount of GH₵10,682,225.25 in 2022. The Deputy Director in charged of claims, Mr. Isaac Akonde said the figure was for the Northern, North East, Savannah, Upper East and Upper West regions.
“For Northern Region, we were able to save the authority some GH₵2.7 million but when you put the aggregates together, we have GH₵10.6 million” he disclosed.
Mr. Akonde explained that, “When the claims are submitted to the CPC, it goes through a very rigorous assessment and reviews to understand what went on at the care givers end – there are a lot of protocols, guidelines and standards that is expected by service providers to follow”.
He stated those same standards, guidelines and policies are what the NHIS uses to vet the claims, adding, sometimes the provider has submitted claims but they have flouted some of those guidelines and standards.
“And when they do it amounts to what we call deductions or adjustments of the claims; so, the person may submit claims of GHS100,000 but after we gone through the claims with checking as against the standard, the processes, the procedures and all of that, maybe we can only recommend for the payment of 90,000 or 95,000” he emphasized.
Speaking in an interview with Journalists on the sidelines of the Northern Region End of Year 2022 Review Meeting on Monday (February 27, 2023) in Tamale, the Deputy Director stated there are various reasons that account for these infractions.
He maintained that some of them maybe deliberate attempts allegedly by service providers to scheme the system and also attributed a large quantum of them to errors committed by the providers.
Mr. Isaac Akonde indicated some of the claims do not match with the diagnosis that the patient came with and in such a situation they are unable to pay for that medicine.
He stressed the NHIS benefit package comes with various tariffs for every condition of a patient and pointed out each of the tariffs has their own amount.
“Sometimes the tariffs you’re supposed to apply for every condition the patient comes with on the NHIS benefit package, each of the tariffs their own amount and so you may treat somebody with malaria but you have gone to use the tariff of somebody with hypertension – that amount maybe higher than malaria [so what do we have to do], we would have to take the difference between the malaria tariff and the hypertension tariff, so that would also be an adjustment.”
He continued that, “So of them may just omit things they’re not supposed to omit, for example, if you leave the NHIS number on the claims form, we can’t pay for that claim because we aren’t sure if the person is an NHIS member in the first place, second we aren’t sure whether the card that time you were giving the service is active with the NHIS and so if you leave out certain mandatory information or data that you’re supposed to put on the claim form which you have failed to do, it will amount to a deduction.”
Meanwhile, it emerged that in the year under review the volume of claims submitted using the NHIA digital technology were more than the manual claims but the corresponding payments were vice versa.
In view of this, the CPC Deputy Director encouraged service providers to take advantage of the digitization drive in order to avoid the financial burden in preparing the manual claims processes.
