A predictive model of finance claims rejection under the national health insurance scheme( A case study of selected health service providers in Ashanti region)

Abstract

Access to quality healthcare is fundamental to economic progression as healthy populations live longer, are more productive, and save more. The National Health Insurance Scheme (NHIS) was established by the Government of Ghana in 2003 through an Act of Parliament to provide accessible and quality Healthcare services to residents of Ghana. It replaced the Cash and Carry system which took a toll on healthcare delivery in the country. The scheme has however been facing claims management and financing challenges. This study provides a predictive model based on factors that affect claims rejection. An explanatory research design was employed, and a multiple linear regression model developed to evaluate the impact of identified factors namely; errors, fraud, adequacy of personnel, the level of bureaucracy and adequacy of logistics on claims rejections for a stipulated period of a year. The regression model revealed that the identified factors account for approximately 89% of the variations in claims rejection. The model showed that errors and inadequacy of personnel account significantly for claims rejection under the National Health Insurance Scheme. As a result, the study recommends among others, increased advocacy, sensitization and training of health service providers and subscribers of the scheme on the impact of fraud and abuse on the health insurance system as well as institution of a sophisticated E-claims system to minimize duplications and errors which lead to Claims rejection.