HAWA MEMORIAL SAVIOUR HOSPITAL A PROGRESS REPORT ON THE HSS IMPLEMENTATION PROGRAM( NHIS ) BY PETER DUAH

BPHARM, MPSGH, IEMBA-healthcare mgt

INTRODUCTION
 Located: Osiem, EAM, E/R  Began : 13th September 2008 & was officially inaugurated in 17th

October 2009
 NHIA Accreditation & Implementation : 1st December 2009  CHAG member in November 2009

INTRO CONT.
The management of HMSH, intends t0 improve the

efficiency of its health insurance claims management to minimize revenue leakages due to errors in processed claims and to avert the issue of untimely submission and reduce deductions.

Reasons for deductions / rejections

y Billing scheme with drug quantities which were not found in patients folders. y Over casting. y Wrong pricing of drugs. y Irrational prescription of drugs. y Wrong tariff charge of detention for observation and treatment.

Overall Objective
y To ensure that all forms of deductions and rejections

are eliminated and to submit processed claims at most two weeks of the ensuing month through the following programs and actions.

y System blocks:

Health technology
Health Information Human resource for health Leadership & Governance

Health Technology
y Objective: To procure 3 computers by the end of June

2011 for claims processing y Indicator: Error free claims; Timely submission y Measure: rejection rate; Submission deadline y Activity: procure 3 desktop computers for claims processing by June 2011 y Level of implementation: 9 computers & accessories were procured in October; y Budget approved: GHC3,600.00 y Amount spent: GHC13,000.00

Health Information
y Objective: To acquire claims processing software by

end of June 2011 y Indicator: Error free claims; Timely submission y Measure: rejection rate; Submission deadline y Activity: Procure one NHIS software by June 2011 y Level of implementation: PHIS procured in October 2011 after networking the institution y Budget approved: 4650.00 y Amount Spent:GhC9650.69

Human Resource for Health

Objectives  To recruit two health insurance staff by end of July 2011;  To build capacity of all staff involved in NHIS claims preparation and management by June 2011  To train staff on use of the NHIS software by June 2011
y y y

Indicator: Error free claims; Timely submission Measure: rejection rate; Submission deadline Activity:
y y y

To recruit one systems administrator and one other staff with accounting background To train 24 staff involved with claims processing and management by July 2011 To train 9 staff who are direct contact with the input of information onto the software by July 2011

Level of implementation: y a personnel with accounting background has been recruited however a staff has been trained for management of the software y Instead of 24 staff, 78 were trained y Training of the direct users ongoing for 22 personnel y Budget approved: GhC 2812.00 Amount spent: GhC 3592.00

Leader & Governance

Objectives  To enhance capacity of claims vetting committee for effective monitoring of claims by end of June 2011;  To develop performance goals and targets for the insurance unit by April 2011
y Indicator: Error free claims; Timely submission y Measure: rejection rate; Submission deadline y Activity: y To train 5 members of the vetting committee by April 2011 y To develop SOP s and set target for insurance staff by April 2011

y Level of implementation: y Vetting committee members (5) were trained on common errors in claims management in May 2011 y SOP s developed

SOP s
y To monitor the progress of work of the insurance unit on daily basis(Finance Manager) y Work is structured such that the day s OPD attendances is worked on the preceding day y In-patient claims are also collected & processed on Monday s, Wednesday s and Friday s y Vetting committee members were to initiate vetting at their various places of work y Regular vetting committee meeting on Saturdays & Sundays

Challenges
y Reluctance on the part of MHIS to give breakdown on

the itemized cost of adjustments and rejections made. y Extra finance committed to the program by management has over stretched its overburdened budget y Resistance to change at the start of the program

Impact
INDICATOR 1.No. of Claims submitted 2.No of rejected claims 3. No. Of claims Adjusted 4. Date of submission 5. Submission deadline met JAN 2649 FEB 2477 MARCH 3519 APRIL 3447 MAY 3141 JUNE 3102 JULY 3733 6 15 11 11 1 2 0

150

124

185

174

613

37

21

11/02/2011 YES

8/03/2011 YES

18/04/2011 NO

16/05/2011 NO

9/06/2011 YES

11/07/2011 YES

8/08/2011 YES

Success factors
y Management has been committed to the program. y Coordination of the various units y Regular interactions with NHIA officers on issues

pertaining to claims management

y Regular feedback from NHIA officers on claim

processing report

Recommendation
Funds should be sourced to do more of these programs

Unexpected Results: May 2011 adjustments