Reducing medical claims cost to Ghana’s National Health Insurance scheme: a cross-sectional comparative assessment of the paper- and electronic-based claims reviews

Eric Nsiah-Boateng, Francis Asenso-Boadi, Lydia Dsane-Selby, Francis Xavier Andoh-Adjei, Nathaniel Otoo, Patricia Akweongo, Moses Aikins

Research output: Contribution to journalArticlepeer-review

13 Citations (Scopus)

Abstract

Background: A robust medical claims review system is crucial for addressing fraud and abuse and ensuring financial viability of health insurance organisations. This paper assesses claims adjustment rate of the paper- and electronic-based claims reviews of the National Health Insurance Scheme (NHIS) in Ghana. Methods: The study was a cross-sectional comparative assessment of paper- and electronic-based claims reviews of the NHIS. Medical claims of subscribers for the year, 2014 were requested from the claims directorate and analysed. Proportions of claims adjusted by the paper- and electronic-based claims reviews were determined for each type of healthcare facility. Bivariate analyses were also conducted to test for differences in claims adjustments between healthcare facility types, and between the two claims reviews. Results: The electronic-based review made overall adjustment of 17.0% from GHS10.09 million (USD2.64 m) claims cost whilst the paper-based review adjusted 4.9% from a total of GHS57.50 million (USD15.09 m) claims cost received, and the difference was significant (p < 0.001). However, there were no significant differences in claims cost adjustment rate between healthcare facility types by the electronic-based (p = 0.0656) and by the paper-based reviews (p = 0.6484). Conclusions: The electronic-based review adjusted significantly higher claims cost than the paper-based claims review. Scaling up the electronic-based review to cover claims from all accredited care providers could reduce spurious claims cost to the scheme and ensure long term financial sustainability.

Original languageEnglish
Article number115
Pages (from-to)1-7
Number of pages7
JournalBMC Health Services Research
Volume17
Issue number1
DOIs
Publication statusPublished - 6 Feb 2017

Keywords

  • Claims adjustment
  • Ghana
  • Medical claims review
  • National Health Insurance Scheme

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