Department of Public Administration and Health Services Management, University of Ghana Business School, University of Ghana, Legon, Accra, Ghana.
Management Department, Pharm Access Foundation, East Legon, Accra, Ghana.
PLoS One. 2022 Oct 5;17(10):e0275493. doi: 10.1371/journal.pone.0275493. eCollection 2022.
Inadequate, inefficient and slow processing of claims are major contributors to the cost of health insurance schemes, and therefore undermining their sustainability. This study uses the Technology, Organisation and Environment (TOE) framework to examine the preparedness of health facilities of the Christian Health Association of Ghana (CHAG) to implement a digital mobile health insurance claims processing software (CLAIM-it), which aims to increase efficiency.
The study used a cross-sectional mixed method design to collect data (technology and human capital capacity and baseline operational performance of claims management) from a sample of 20 CHAG health facilities across Ghana. While quantitative data was analysed using simple descriptive statistics statistics (frequencies, mean, minimum and maximum values), qualitative interviews were recorded, transcribed and abstracted into two major themes that were reported to re-enforce the quantitative findings.
The quantitative results revealed challenges including inadequate computers and accessories, adequate numbers and skills for claims processing, poor intranets and internet access, absence of a robust post-implementation support system and inadequate standard operating procedures (SOPs) for seamless automation of claims processing. In addition to the above, the qualitative results emphasised the need to make CLAIM-it more flexible and capable of being integrated into third-party softwares. Notwithstanding the challenges, decision-makers in CHAG health facilities see the CLAIM-it software as having better functionality and superior capabilities compared to existing claims processing systems in Ghana.
Notwithstanding the challenges, the CLAIM-it software is more likely to be adopted by decision-makers, given the positive perception in terms of superior functionality. It is important that key actors in claims management at the National Health Insurance collaborate with relevant stakeholders to adopt the CLAIM-it software for claims processing and management in Ghana.
理赔处理不充分、效率低且速度慢是导致医疗保险计划成本增加的主要因素，从而破坏了其可持续性。本研究使用技术、组织和环境（TOE）框架，考察加纳基督教健康协会（CHAG）的卫生机构实施数字移动医疗保险理赔处理软件（CLAIM-it）的准备情况，该软件旨在提高效率。
本研究采用跨截面混合方法设计，从加纳 20 家 CHAG 卫生机构的样本中收集数据（技术和人力资本能力以及理赔管理的基准运营绩效）。虽然使用简单描述性统计数据（频率、平均值、最小值和最大值）分析定量数据，但对定性访谈进行了记录、转录和抽象为两个主要主题，以加强定量发现。
定量结果揭示了一些挑战，包括计算机和配件不足、理赔处理人员数量和技能不足、内部网和互联网接入差、缺乏强大的实施后支持系统以及缺乏无缝自动化理赔处理的标准操作程序（SOP）。除上述挑战外，定性结果还强调了需要使 CLAIM-it 更具灵活性，并能够集成到第三方软件中。尽管存在挑战，但 CHAG 卫生机构的决策者认为 CLAIM-it 软件的功能优于加纳现有的理赔处理系统。
尽管存在挑战，但鉴于在功能方面的积极看法，CLAIM-it 软件更有可能被决策者采用。在加纳，理赔管理的关键参与者与相关利益相关者合作采用 CLAIM-it 软件进行理赔处理和管理非常重要。
