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



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.



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).



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.
National Health Insurance Authority, Accra, Ghana. ensiah-boateng@st.ug.edu.gh.|School of Public Health, University of Ghana, Accra, Ghana. ensiah-boateng@st.ug.edu.gh.
Eric
0000-0001-5217-9805
E
Nsiah-Boateng
National Health Insurance Authority, Accra, Ghana.
Francis
F
Asenso-Boadi
National Health Insurance Authority, Accra, Ghana.
Lydia
L
Dsane-Selby
National Health Insurance Authority, Accra, Ghana.
Francis-Xavier
FX
Andoh-Adjei
National Health Insurance Authority, Accra, Ghana.
Nathaniel
N
Otoo
School of Public Health, University of Ghana, Accra, Ghana.
Patricia
P
Akweongo
School of Public Health, University of Ghana, Accra, Ghana.
Moses
M
Aikins
D017046:Cost Savings; D003430:Cross-Sectional Studies; D057286:Electronic Health Records; D005607:Fraud; D005869:Ghana; D006268:Health Facilities; D006801:Humans; D007345:Insurance Claim Review / Q000191:economics*; D007348:Insurance, Health / Q000706:statistics & numerical data; D009313:National Health Programs / Q000191:economics*; D010209:Paper
Claims adjustment; Ghana; Medical claims review; National Health Insurance Scheme