TECHNOLOGY FOR DEVELOPMENT

JOMO KENYATTA UNIVERSITY OF AGRICULTURE AND

TECHNOLOGY

DEPARTMENT OF STATISTICS AND ACTUARIAL SCIENCES

BACHELOR OF SCIENCE IN OPERATIONS RESEARCH

MOKUA MERCY FLAVIA MORAA

SCM 225-0592/2018

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AN INDUSTRIAL ATTACHMENT REPORT CARRIED OUT AT

THE NATIONAL HOSPITAL INSUARANCE FUND

PROGRAM: BACHELOR OF SCIENCE OPERATIONS RESEARCH

NAME: MOKUA MERCY FLAVIA MORAA

REGISTRATION NUMBER: SCM 225-0592/2018

YEAR OF STUDY: 3RD YEAR

ACADEMIC YEAR: 2020/2021

STA 2410: INDUSTRIAL ATTACHMENT

HOST INSTITUTION: NATIONAL HEALTH INSURANCE FUND

(KISII BRANCH)

ATTACHMENT PERIOD: 18TH OCTOBER – 28TH DECEMBER

DATE OF SUBMISSION: 12TH JANUARY

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DECLARATION

I hereby declare that this report on industrial attachment at the National

Insurance Fund presented to Jomo Kenyatta University of Agriculture and

Technology, department of Statistics and Actuarial sciences, is my original

work as the outcome of my investigation during the period of my

industrial training.

Signature.................................... Date..........................

Name of Student ........................................................

Registration Number....................................................

This report has been submitted for examination with my approval as the

industrial based supervisor.

Signature.................................... Date..........................

Name of Supervisor........................................................

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ACKNOWLEDGEMENT

First and foremost, I am sincerely grateful to The Almighty God for

enabling me take this industrial training and as well as the fraternity of

Jomo Kenyatta University for encouraging me to seek this opportunity to

get exposed in the work environment to apply practical knowledge from

theoretical principles.

I will not go without making mention and thanking the host institution,

National Hospital Insurance Fund, for making this attachment exercise a

huge success. Their in valuable cooperation and unwavering support

from the management and staff who enabled me gain much more

especially my supervisor for his guidance, remarks, and relevant

suggestions throughout my training.

I would like to extend my heartfelt gratitude to my family members

especially my parents for their labour of love to ensure that I was

comfortable financially and intellectually through their words of wisdom.

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EXECUTIVE SUMMARY

This report is compiled in partial fulfillment to the award of Bachelor of

Science Degree in Operations Research and it serves to provide an

overview of what I learnt during the attachment period at NHIF for the 8

weeks training. The sources used in writing this report includes

observations of underwriting materials that have been carried out by the

company and reading from internet. This report gives a brief introduction

to the National Health Insurance Fund including its background, main

functions, vision and mission statements, objectives of NHIF, its core

values, organizational structure and how appointments to the top positions

are performed. It also summarizes the key functions of the host

department, the main objectives of my training, my assigned duties within

the department and suggestions on efficient service delivery and

operations of the department. It later, discusses the benefits I reaped from

the attachment exercise, my major contributions to the firm, the skills I

gained and the loopholes I observed at the firm.

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TABLE OF CONTENTS

Declaration……………………………………………… 2

Acknowledgement……………………………………… 3

Executive summary…………………………………… 4

1. INTRODUCTION

1.1 History of the firm…………………… 6

1.2 Main functions of NHIF…………………… 6
1.3 Vision statement……………………………… 7
1.4 Mission statement……………………………… 8
1.5 Objectives of NHIF………………………… 8
1.6 Core values of NHIF………………………… 8
1.7 Organizational structure of NHIF…………… 9

2. THE CLAIMS AND BENEFITS DEPARTMENT

2.1 Key activities of the claims and benefits department……… 11
2.2 Assigned routine duties………………………………… 11
2.3 Suggestions on efficient delivery…………………… 13

3. EVALUATION OF THE ATTACHMENT PERIOD

3.1 Benefits of the attachment exercise …………………… 14
3.1.1 Achievements during attachment……………… 14
3.1.2 Theoretical achievements………………………… 15
3.2 Major contribution to the firm …………………………… 15
3.3 Skills learnt……………………………………………… 16
3.4 Loopholes observed at the firm………………………… 17

4. CONCLUSIONS AND RECOMMENDATIONS

4.1 Conclusions……………………………………… 18
4.2 Recommendations…………………………… 19

5. REFERENCES

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CHAPTER ONE: INTRODUCTION

1.1 HISTORY OF THE FIRM

NHIF was established under Cap 255 of the Laws of Kenya in 1966 as a

department in the Ministry of Health to provide health insurance

exclusively for those in the formal employment. In 1972 an amendment

was made to allow for membership for those in the informal sector,

commonly known as the self-employed. The fund was then transformed

into a state corporation through an act of parliament, NHIF Act No 9 of

1998.

1.2 MAIN FUNCTIONS/ CORE ACTIVITIES OF NHIF

NHIF exclusively offers health coverage to registered members in the

form of packages which are delivered through a capitation model. These

packages include:

 Inpatient cover; - Covers all necessary medical treatment and

services provided by or on the order of a clinician to the member

when admitted to an NHIF Accredited Hospital offering services

under levels as defined by the Kenya Essential Package for Health

(KEPHA)

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  Outpatient Cover; Includes consultation, lab investigations, drug

administration and dispensing, dental healthcare services, optical

care among other benefits.

 Maternity Cover and Reproductive Health; This includes

delivery and caesarian section for reproductive health. Cover caters

for family planning services, excluding fertility treatment. This

benefit, however, is not available for dependents other than the

declared spouse.

 Ex-Gratia Payments; NHIF is not liable for ex-gratia payments

upon the limits being exhausted.

 Group life Cover: NHIF pays death benefit upon demise of a

member whilst in service subject to provision and receipt of full

documentation.

 Last Expense Cover; NHIF upon written notification of death of a

member while this cover is in force, pay to the client or such other

person s as the client may in writing direct, the amount specified in

the schedule to cater for the funeral expense.

1.3 VISION STATEMENT

The fund’s vision statement is; “A world class universal social insurer”

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1.4 MISSION STATEMENT

To contribute towards Universal Health Coverage through provision of

affordable, accessible, sustainable and quality health insurance through

strategic resource pooling and healthcare purchasing in collaboration with

stakeholders.

1.5 OBJECTIVES OF NHIF

The objectives of the firm as outlined in their service charter is to:

 Increase the number of principal members from 7 million in 2018

to 19 million by 2022

 Enhance revenue inflow and its utilization

 Enhance compliance to good governance

 Enhance synergies in information and revenue sharing with

stakeholders and partners

1.6 CORE VALUES OF NHIF

NHIF is striving to create an organization that will foster:

 Customer responsiveness

 Ethics and professionalism

 Team spirit

 Partnerships and Collaborations

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  Innovation and creativity

 Corporate social sustainability

1.7 ORGANISATIONAL STRUCTURE OF NHIF

CEO

DIRECTOR DIRECTOR DIRECTOR DIRECTOR

REGISTRATION MARKETING FINANCE AUDIT

AND AND AND

COMPLIANCE PLANNING CONTROL

REGIONAL MANAGERS

BRANCH MANAGERS

HEAD OF BRANCH HEAD OF HEA HEAD OF

CLAIMS ACCOUNTANT REGISTRATION D OF PROCUREMENT

AND AND COMPLIANCE ICT

BENEFITS

CLAIMS REGISTRATION ACCOUNTS ICT PROCUREMENT

OFFICERS AND ASSISTANTS OFFICER OFFICER

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 COMPLIANCE

OFFICERS

CLARICAL OFFICERS

SUPPORTSTAFF

CHAPTER TWO: THE CLAIMS AND BENEFITS

DEPARTMENT

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2.1 KEY FUNCTIONS/ACTIVITIES OF THE DEPARTMENT

The claims and benefits section was my host department during my

training at NHIF. It serves as the primary capitation unit of the

organization. The following are some of the functions of the benefits and

claims department:

 Receiving, signing and stamping claim forms from accredited

hospitals and health facilities.

 Carefully checking the received claims forms for the necessary

attachments and requirements before forwarding to accounts

department.

 Updating the received claims into the fund’s system.

 Authorizing the already inspected claims forms for payments.

 Returning the substandard claim forms back to the respective

hospitals for correction where necessary.

 Advising the hospital and health facility representatives on the

approved channeling of claims including the necessary

requirements for payments.

2.2 ASSIGNED ROUTINE DUTIES AT THE DEPARTMENT

Upon reporting, I was delegated to help at the Registration and

Compliance Department temporarily. My duties in this included;

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  Responding to customer queries and concerns

 Registering new members into the firm’s system (NHIF 2)

 Amending member’s particular’s (NHIF 26)

 Printing NHIF cards for clients

After a period of one month, I was transferred to the claims and benefits

section where I spent the rest of my attachment days. Below are the

duties I was assigned in this department

 Inspecting the physical claim forms for possible errors

 Receiving claim forms, examining carefully for any contradicting

information

 Forwarding the received claims to the head of department for

checking

 Authorizing the received claims for payments where necessary

 Updating the received claim forms into the firm’s system

 Advising the hospital representatives on the right order to attach

the necessary requirements and responding to their enquiries

 Running other miscellaneous errands such as typing documents,

photocopying and any other task that could require my help.

2.3 SUGGESTIONS ON EFFICIENT SERVICE DELIVERY

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After working with the claims and benefits department for a period of two

months, I would like to suggest the following improvements to aid in

efficient and timely service delivery;

 If possible, additional staff should be employed to speed up service

delivery.

 The firm should consider a power back up plan in case of blackout.

This would help solve the issue of having to start working on a file

afresh whenever there is blackout.

 The firm should stabilize its system, sometimes it becomes too

slow thus retarding updates and hence payments at large.

 Interns should be given login rights save for attachés. This would

help whenever the top officials aren’t around.

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CHAPTER 3: EVALUATION OF THE ATTACHMENT
PERIOD
3.1 BENEFITS OF THE ATTACHMENT EXERCISE

With respect to my objectives during the attachment training, the whole

exercise has been a success and all my objectives were achieved.

I learned a lot of things which added to my experience in the actuarial

field. Apart from the practical skills acquired in my career, I also gained

new theoretical skills about my field of study which are of great

importance to my knowledge and understanding about claims and

benefits.

3.1.1 Achievements during the attachment exercise

From my assigned duties and responsibilities, I was able to make the

following achievements

 Learnt how to inspect claim forms, including what to look for

in a claim form for it to qualify for payment.

 Learnt how to authorize claims for payment

 Learnt how to relate the information in the physical claim

form to that in the firm’s system and thus identify any

possible mischief in the claims submitted for processing.

 I learnt how to process both inpatient and outpatient claims

each with their necessary requirements for processing

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  I also learnt how to process EDU-AFYA claims, Linda Mama

outpatient and inpatient claims, Linda Mama Deliveries; all

with their specific requirements

 I learnt how to print cards, scan documents, and operate the

office machines and mailing.

 I also learnt how to file documents and trace the files if

needed later.

3.1.2 Theoretical achievements

Apart from the practical experience gained as I was taken to the field

for a period two week ,I also had the opportunity to learn the

following theoretical work;

 The whole procedure of making claims

 Registry procedures

 OHSAS act and regulations

(OHSAS is one of the International Standard for Occupational

Health and Safety Management Systems)

3.2 MAJOR CONTRIBUTION TO THE FIRM

While at the firm, I and my fellow interns took it upon ourselves that the

claims desk was ever empty, this led to efficient and timely payments to

hospitals and health facilities.

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I enlightened the hospital representatives on the latest requirements for

payment processing of claims, and how to avoid rejection of their claim

forms.

3.3 KNOWLEDGE AND SKILLS/LEARNING EXPERIENCE

ACQUIRED

My training experience has aided me in analyzing my options and my

situation. During the attachment period, I gained skills in three different

axes.

Professionally: Especially from the branch manager, who exuded an aura

of true leadership in the way he carried himself around, performed his

tasks, his dressing code; everything about him spoke professionalism.

Customer relations- I should not involve any emotions while serving

customers. I also had the opportunity to put into practice what I have been

learning in class like the claims and benefits as a unit, how payments are

done, capitation and the whole process of making a claim.

Socially, I have gained a greater level of confidence through my

interactions with people from different calibers and even the top officials.

I have learnt good interpersonal skills, how to relate with colleagues and

teamwork as an important virtue in the work environment.

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Individually, I learnt about time management as an important part of the

industry. Neatness; official dressing at all times.

3.4 LOOPHOLES OBSERVED IN THE FIRM

The following are some of the loopholes I observed that needed

improvement;

 Understaffing, some of the departments do not have enough

manpower leading to delays in service delivery.

 Insufficient power backup plans, with only the registration and

compliance department having a power backup plan, the rest of the

departments should also be considered.

 Insufficient printing cards, which frustrated most of the clients as

they had to wait for so long, especially during the Covid19 period.

 Frauds: Especially by hospitals who claim payments for faked

services.

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CHAPTER 4: CONCLUSION AND RECOMMENDATIONS

4.1 CONCLUSION

The supervised industrial attachment of the university gives students the

opportunity to apply what has been learnt in class into practice. This

exposes them to practical skills which are often not covered in class.

Industrial attachment also provides an opportunity for students to assess

their interests in their career and also acquaint them with the expectations

of working in a highly competitive environment.

The training strengthens the linkages between the university and other

institutions all over the country. In review, the training has been a success

and I was able to gain practical skills, work in a warm environment and

make connections with different types of people. This attachment with

NHIF has instilled practical knowledge and experience in my field of

study (actuarial science) as well as enriching me with the interactions with

the business world.

The training has instilled in me personal integrity namely; punctuality,

submissiveness to and taking views of supervisors, communication skills

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and efficiency in task and problem management. As a result, my

objectives were met and well achieved. Not only did I gain practical skills

but also acquired management, self-motivation and good interpersonal

skills.

This training program should therefore be maintained for students to learn

more practically as this has been an excellent and rewarding experience

and I hope other interns gained as much as I did.

4.2 RECOMMENDATIONS

The following should be put in place to assist in the operations of NHIF

and to better the learning experience for interns

 Provide power backups for all departments.

 Strengthen hospital surveillance to reduce frauds.

 If possible, employ additional staff in the understaffed

departments.

 Timely delivery of sufficient printing cards. The period of

processing the spouse updates after provision of marriage affidavit

should be lessened too.

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 Stabilize the organization’s system. The organization can also

consider doing maintenance and system updates during weekends

and non-working hours.

 Staff motivation; a token for the top performing departments once

in a while would help uplift the staff’s spirits which would translate

into efficient and improved service delivery.

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REFERENCES

 NHIF official website

 OHSAS official webpage
 IA guidelines on report writing and cover page compilation
provided by J.K. Omurundo
 https://teamsumbasu.wordpress.com
 www.academia.com

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