TY - JOUR
T1 - Reducing medical claims cost to Ghana’s National Health Insurance scheme
T2 - a cross-sectional comparative assessment of the paper- and electronic-based claims reviews
AU - Nsiah-Boateng, Eric
AU - Asenso-Boadi, Francis
AU - Dsane-Selby, Lydia
AU - Andoh-Adjei, Francis Xavier
AU - Otoo, Nathaniel
AU - Akweongo, Patricia
AU - Aikins, Moses
N1 - Publisher Copyright:
© 2017 The Author(s).
PY - 2017/2/6
Y1 - 2017/2/6
N2 - 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.
AB - 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.
KW - Claims adjustment
KW - Ghana
KW - Medical claims review
KW - National Health Insurance Scheme
UR - http://www.scopus.com/inward/record.url?scp=85011552149&partnerID=8YFLogxK
U2 - 10.1186/s12913-017-2054-1
DO - 10.1186/s12913-017-2054-1
M3 - Article
C2 - 28166773
AN - SCOPUS:85011552149
SN - 1472-6963
VL - 17
SP - 1
EP - 7
JO - BMC Health Services Research
JF - BMC Health Services Research
IS - 1
M1 - 115
ER -