QUESTION ONE:

Case Study Analysis: Digitalizing Claims Management at National Health Insurance Scheme (NHIS)

Background

The National Health Insurance Scheme (NHIS) is financed primarily by tax revenue, and claims make up the

bulk of its expenditures, The NHI levy provides seventy four percent (74%) of NHIS revenue, Social Security

and National Insurance Trust (SSNIT) deductions comprise another 20 percent, and premium payments provides

just three percent. However, claims payments accounts for seventy seven percent (77) of NHIS expenditures.

Due to the low level of Ministry of Health (MoH) spending on goods and services. NHIS claims payments

represent over eighty percent (80) of health facilaties operational expenses.

All residents of Ghana, including non-citizens, are eligible for NHIS coverage, but not all enrollees are required

to pay premium. SSNIT contributors do not pay premiums, nor do enrollees under the age of eighteen (18) or

over the age of seventy (70) as well as indigent people are also exempted from premium payments.

Claim

Claims management is a vital component of NHIS operations. On average, National Health Insurance Authority

(NHIA) processes two million four hundred thousand (2,400.000) claims each month. For example, in 2014,

claims expenses accounted for seventy seven percent (77%) of NHIS expenditure composition. Most claims

are submitted via paper forms, only eight percent (8%) are submitted electronically via other NHIS applications.

Once providers submit their claims, the NHIA subjects them to a five step process: fulfillment, vetting, data

entry, vetting-report generation, and payment request initiation. A typical vetting-report include: information

on the total amount deducted for a given batch of claims from each facility. However, some providers have

complained that these reports do not include specific information on individual calms.

A recent World Bank study of the Ghana National Health Insurance Scheme revealed that claims expenditures

vary significantly between individual facilities, even those of the same types. Per-claim expenditures for

outpatient services at primary hospitals ranges from eighteen Ghana cedi (GHc18) to hundred and twelve Ghana

cedi (GHc112), a sixfold difference. The median claim value for primary hospitals is twenty four Ghana cedi

(GHc24), and per-claim expenditures at the top five hospitals is at least fifty (50) higher than the median. A

similar but less drastic pattern is observed for inpatient services, per-claim expenditures which range from one

hundred and twenty-one Ghana cedi (GHc121) to Two hundred and sixty-two Ghana cedi (GHc262) (World

Bank, 2017).

NHIAs existing claims-vetting system is not properly equipped to identify abnormal behavior among services

providers. Claims offer a wealth of information on expenditure patterns, but most of the data captured by the

NHIA are not analyzed. A number of reasons account for this phenomenon. First, existing data are not available

in a format conductive to analysis. For example, analysis of more than three thousand (3000) individual claims

Excel files from the Volta region submitted in 2014 show these files are not consistently formatted, and terms

are used inconsistently. Addressing these issues is a costly and time-consuming process. While the NHIA has

been working to develop standard templates, these issues remain widespread in all regions. Second, the data

captured by the current system are insufficient to verify the accuracy of the specified GDRG or appropriateness

of the treatment. The NHIA requires facilities to submit a claims summary that includes the patients

membership identification number, GDRG, diagnosis, facility name, visit date, total cost, medicine and services

cost. However, only one diagnosis is included for each claim, and no information on prescription drugs is

included. Claims also lack information on patients health status, which makes it difficult for NHIS to determine

whether the diagnosis and GDRG coding were accurate and whether the treatment was appropriate. Third,

claims data are not integrated with other databases. Consequently, these data cannot be automatically cross-

referenced against the membership database, the database of facility characteristics, or the overall health

management information system. The information can be compared manually with special efforts, but this is

not a routine practice for the NHIA.

Claims processing by NHIA is labor-intensive and inefficient. Claims are vetted on an individual basis. Most

claims are evaluated manually, given the relatively small share that are electronically submitted. The NHIA

expends a staggering one thousand two (1,200) to four thousand eight hundred (4,800) staff weeks vetting, each

months claims, and maintaining this schedule requires hundreds of staff members. The NHIA has about one

hundred and fifty (150) NHIA district offices and four (4) NHIA claims processing centers.

Provider Payment

The NHIS payment system does not promote cost-consciousness among service providers and encourage

oversupply of services. Because health care facilities typically rely on the NHIS reimbursement to recover their

operating expenses, they have no incentive to be efficient in claims expenditure. Furthermore, NHIS reimburses

private facilities at higher rates, while public facilities appear to be underutilized. The wage bill for the public

health workers reached one billion five hundred million (GHc1.5 b) in 2014, but the available data indicate that

publicly financed health care workers only see an average of 2 -2.9 outpatients per working day. Meanwhile, a

large share of NHIS Claims expenditures flows to private facilitates

Previous claims-expenditure reviews have shown that some service providers exhibit abnormal behavior that

may indicated fraud or abuse and that warrants additional scrutiny. Private facilities, which tend to be high-cost

providers, are more likely that other facilities to submit incomplete claims information. Furthermore, among

private clinics that submit claims without GDRG information, fourty two (42) percent also lack diagnosis

information, making it impossible to determine whether the GDRG is appropriate and these claims expenditure

are eligible for reimbursement.

Under the NHIS, providers were initially paid only on a fee-for-service (FFS) basis, but over time the payment

system evolved to encompass Ghana-diagnosis-related-groups (GDRG) and capitation. As FFS payments can

incentivize an oversupply of services, GDRG and capitation payments were introduced to contain costs. While

the capitation payments are used for outpatient primary care in some regions of Ghana, GDRG are used for all

inpatient care, all outpatient care in non-capitation regions, and outpatient care in capitation regions.

Pharmaceutical costs are still reimbursed to providers on an FFS basis, which reflects predetermined tariffs and

quantities of drugs submitted by providers.

But there are limited opportunities for the NHIS members to provide feedback on their experiences. After

members visit health care facilities, claims are submitted under their names by facilities, but there is no

interaction between members and NHIA. There is no standard mechanism for their NHIA to confirm receipt of

services, service quality, payment problems or any other issues encountered by the members

Service providers

Private health care providers received higher GDRG tariffs and capitation rates to compensate for the lack of

public funding. Public providers (including Christian Health Association of Ghana (CHAG-facilities) receive

funding from MoH, whereas private providers do not receive it. Consequently, tariff rates differ significantly

by facility type and ownership. For example, the reimbursable cost of a general consultant for an adult patient

is 76 percent higher for private primary hospital and 48 percent higher for a private clinic than it is for a public

primary hospital.

NHIA Board Meeting: Enhancing expenditure management at the NHIS

The NHIAs electronic claims-processing system should be expanded and redefined. The information provided

by this system is significantly better than the summary data submitted in Excel files. However, the system covers

only eight percent (8%) of total claims. Moreover, only the submission stage is electronic, and the vetting

process remains manual. In addition, data on the NHIA server can only be accessed by special request. An

enhanced electronic claims processing system should have increased capacity, algorithms for automated vetting,

and linkages to other public health databases. Developing systems to identify and track patients could improve

the efficiency of claims expenditures and reduce errors and abuse.

Source: Excerpts from National Health Insurance Scheme Report, 2017 (Credit to the World Bank Group)

Required:

1. Identify, analyse (using power/interest) and attitudes of stakeholders. Note that there can be more

stakeholders than mentioned above. (6 marks)

2. Represent the current state described above with models and the IT structure. (3 marks)

3. What would the future state look like? Please use the same models as with the current state analysis

and consider the constraints or the restrictions that may apply. (6 marks)

4. What alternative solutions can you identify given the information above (and perhaps with making

reasonable assumptions)? (6 marks)

5. Based on your digital solution, identify and list the functional requirements and if there are any

transitional requirements (12 marks)