The Director of Claims, National Health Insurance Authority (NHIA), Dr Lydia Dsale Selby, has disclosed that much of the work that goes into processing claims is human intensive, which accounts for the slight hold in paying claims.
According to her, though NHIA is 10 years old, it is still in its developmental stages and would become more efficient in due course.
Dr Selby revealed these to the press during a tour of their Claims Processing Centre (CPC) in Accra yesterday.
However, she exposed that much of the delay accrues from the back and forth that ensues between the scheme and service providers on the ‘cleanness” of some claims brought to them.
According to her, the media outcry by service providers that NHIA delays unnecessarily in paying claims to them was not correct.
“The claims cannot just be paid immediately because a service provider has brought it to the authority,” she said.
Dr Selbey stated that the payment of a claim goes through a process.
Enumerating the processes, she held that when the providers bring their claims, it is first booked before they go through the first stage of ‘Fulfilment.’
Touching on the ‘Fulfilment’ process, she noted that it is a crucial set where the claims are studied individually to authenticate their monetary value.
“This department saves NHIA a lot of money because blots in the claims are found out at this stage and the provider’s attention is drawn to it,” she believed.
The next step she spoke on is the Vetting process, where the claims are vigorously scrutinised to ensure that diagnosis and medications match.
“During this stage, also, we discover a lot of discrepancies, which we write about to the service providers stating what they are paying for and what they are not going to honour,” she reiterated.
After the Vetting process, she continued that the claims are then moved to the Data Entry section, where the necessary deductions are made based on the anomalies found during the commencement of the process, adding that after which clean claims are archived for a period of seven years.
Speaking on how NHIA deals with anomalies, she said that some of the claims are errors, which they draw the attention of the service providers to; however, some are deliberate to rob the scheme.
Mr Stephen Bewong, Director of the CPC, NHIA, Accra, stated that the CPC also runs an e-claim section where claims are submitted electronically.
“Currently, only 12% of claims we receive at our four centres are done electronically,” he added.
Source: The New Statesman
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