title: Challenges in provider payment under the Ghana National Health Insurance Scheme: a case study of claims management in two districts.
abstract: In 2004, Ghana started implementing a National Health Insurance Scheme (NHIS) to remove cost as a barrier to quality healthcare. Providers were initially paid by fee - for - service. In May 2008, this changed to paying providers by a combination of Ghana - Diagnostic Related Groupings (G-DRGs) for services and fee - for - service for medicines through the claims process.
  
  
  OBJECTIVE
  The study evaluated the claims management processes for two District MHIS in the Upper East Region of Ghana.
  
  
  METHODS
  Retrospective review of secondary claims data (2008) and a prospective observation of claims management (2009) were undertaken. Qualitative and quantitative approaches were used for primary data collection using interview guides and checklists. The reimbursements rates and value of rejected claims were calculated and compared for both districts using the z test. The null hypothesis was that no differences existed in parameters measured.
  
  
  RESULTS
  Claims processes in both districts were similar and predominantly manual. There were administrative capacity, technical, human resource and working environment challenges contributing to delays in claims submission by providers and vetting and payment by schemes. Both Schemes rejected less than 1% of all claims submitted. Significant differences were observed between the Total Reimbursement Rates (TRR) and the Total Timely Reimbursement Rates (TTRR) for both schemes. For TRR, 89% and 86% were recorded for Kassena Nankana and Builsa Schemes respectively while for TTRR, 45% and 28% were recorded respectively.
  
  
  CONCLUSIONS
  Ghana's NHIS needs to reform its provider payment and claims submission and processing systems to ensure simpler and faster processes. Computerization and investment to improve the capacity to administer for both purchasers and providers will be key in any reform.
authors: School of Public Health, College of Health Sciences, University of Ghana, Legon and National Catholic Health Service, Ghana. Sodzi_tettey@hotmail.com
authors: S
authors: S
authors: Sodzi-Tettey
authors: M
authors: M
authors: Aikins
authors: J K
authors: JK
authors: Awoonor-Williams
authors: I A
authors: IA
authors: Agyepong
mesh_terms: D003430:Cross-Sectional Studies; D003906:Developing Countries / Q000191:economics*; D003953:Diagnosis-Related Groups; D018588:Fee-for-Service Plans; D005869:Ghana; D006801:Humans; D007345:Insurance Claim Review / Q000191:economics / Q000458:organization & administration* / Q000592:standards*; D009313:National Health Programs / Q000191:economics / Q000458:organization & administration* / Q000592:standards*; D009816:Office Automation; D012189:Retrospective Studies; D013997:Time Factors; D017132:Workplace
keywords: claims management; claims process; claims rejection; health insurance
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