REASONS FOR NHIS

ADJUSTMENTS/DEDUCTIONS
 INTRODUCTION

• The National Health Insurance Scheme (NHIS) plays a crucial role in

providing healthcare coverage to a large population. However, managing
claims under NHIS often involves adjustments and deductions due to
various reasons. This presentation aims to shed light on the common
issues that lead to such adjustments or deductions. By understanding these
reasons, healthcare providers can improve their practices and reduce the
frequency of claim rejections or adjustments.
 INAPPROPRIATE PRESCRIPTION
• Prescribing incorrect or unsuitable medications for a patient's condition. This can occur due to lack of knowledge,

oversight, or misunderstanding of the patient's medical history.

• Inappropriate prescriptions are a significant issue that can lead to NHIS claim adjustments or deductions. These occur

when medications are prescribed without proper indication or consideration of the patient's medical condition. For

instance, prescribing antibiotics for a viral infection is inappropriate and can lead to claim denials.

Solutions:

• - Implement Clinical Guidelines

• - Continuing Medical Education

• - Electronic Prescription Systems

• - Pharmacy Review
 OVERSUPPLY OF MEDICINES
• Prescribing incorrect or unsuitable medications for a patient's condition. This can occur due to lack of

knowledge, oversight, or misunderstanding of the patient's medical history. For example, supplying a patient

with a three-month supply of a medication that should be reviewed monthly can lead to excess stock and

potential harm.

Solutions:

• - Inventory Management

• - Prescription Duration Guidelines

• - Patient Education

• - Audit and Feedback

 POLYPHARMACY
• Polypharmacy refers to the simultaneous use of multiple medications by a patient, often more than clinically
necessary. This practice can increase the risk of adverse drug reactions, drug-drug interactions, and overall healthcare
costs. Implementing medication reviews and deprescribing protocols can help in managing polypharmacy
effectively.

Example: Tablet Ferrous Sulphate + Folic Acid and Tablet Folic Acid were prescribed together without justification.

Solutions:

• - Medication Review

• - Deprescribing Protocols

• - Patient Involvement

• - Clinical Decision Support

 UNCLEAR DIAGNOSIS
• An unclear or vague diagnosis can lead to inappropriate treatment and subsequent adjustments or deductions
in NHIS claims. For instance, a diagnosis of "general weakness" without specifying an underlying cause can
result in treatments that do not address the actual health issue.
• Example(s):
• “Skin Eruption” was state as a diagnosis without being specific on the kind of skin condition.
• “Trauma/Dermatitis” was stated as diagnosis without further details to justify the treatment given.
Solutions:
• - Comprehensive Clinical Evaluation
• - Diagnostic Training
• - Second Opinions
• - Electronic Health Records (EHRs)
 TREATMENT TO DIAGNOSIS MISMATCH
• Treatment to diagnosis mismatch occurs when the treatment provided does not align with the diagnosed condition. For
example, prescribing painkillers for an infection without addressing the infection itself can lead to claim denials. This
mismatch can arise from misdiagnosis, inadequate clinical assessment, or failure to follow clinical guidelines.
Example(s):
• Tablet Metformin 500mg was prescribed for the treatment of Hypertension.
• Injection Amoxicillin Clavulanic Acid 1.2g was prescribed for the treatment of Asthma.
• Tablet Mebendazole 500mg was prescribed as part of ANC routine medicines without indications.
Solutions:
• - Adherence to Treatment Guidelines
• - Training and Education
• - Multidisciplinary Teams
• - Quality Assurance Programs
 CONCLUSION
• In summary, understanding the common reasons for NHIS adjustments or
deductions is vital for healthcare providers. Inappropriate prescriptions, oversupply
of medicines, polypharmacy, unclear diagnoses, and treatment to diagnosis
mismatches are key issues that need to be addressed. By implementing best
practices and adhering to clinical guidelines, healthcare providers can reduce the
occurrence of these issues, ensuring better patient outcomes and smoother NHIS
claim processes. Continuous education and quality improvement initiatives are
essential in achieving these goals.
Q&A

• Questions and Answers