Nsiah-Boateng Eric, Asenso-Boadi Francis, Dsane-Selby Lydia, Andoh-Adjei Francis-Xavier, Otoo Nathaniel, Akweongo Patricia, Aikins Moses
National Health Insurance Authority, Accra, Ghana.
School of Public Health, University of Ghana, Accra, Ghana.
BMC Health Serv Res. 2017 Feb 6;17(1):115. doi: 10.1186/s12913-017-2054-1.
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.
一个强大的医疗理赔审核系统对于打击欺诈和滥用行为以及确保健康保险机构的财务可行性至关重要。本文评估了加纳国家健康保险计划（NHIS）基于纸质和电子的理赔审核的理赔调整率。
该研究是对NHIS基于纸质和电子的理赔审核的横断面比较评估。从理赔部门获取了2014年参保人的医疗理赔数据并进行分析。确定了每种类型的医疗机构基于纸质和电子的理赔审核所调整的理赔比例。还进行了双变量分析，以测试不同类型医疗机构之间以及两种理赔审核之间在理赔调整方面的差异。
基于电子的审核对1009万加纳塞地（264万美元）的理赔成本进行了总体17.0%的调整，而基于纸质的审核对收到的总计5750万加纳塞地（1509万美元）的理赔成本调整了4.9%，差异显著（p < 0.001）。然而，基于电子的审核（p = 0.0656）和基于纸质的审核（p = 0.6484）在不同类型医疗机构之间的理赔成本调整率没有显著差异。
基于电子的审核调整的理赔成本显著高于基于纸质的理赔审核。扩大基于电子的审核范围以涵盖所有经认可的护理提供者的理赔，可降低该计划的虚假理赔成本，并确保长期财务可持续性。
