Case Study Analysis: Digitalizing Claims Management at National Health Insurance Scheme (NHIS)BackgroundThe National Health Insurance Scheme (NHIS) is financed primarily by tax revenue, and claims make up thebulk of its expenditures, The NHI levy provides seventy four percent (74%) of NHIS revenue, Social Securityand National Insurance Trust (SSNIT) deductions comprise another 20 percent, and premium payments providesjust three percent. However, claims payments accounts for seventy seven percent (77) of NHIS expenditures.Due to the low level of Ministry of Health (MoH) spending on goods and services. NHIS claims paymentsrepresent over eighty percent (80) of health facilaties operational expenses.All residents of Ghana, including non-citizens, are eligible for NHIS coverage, but not all enrollees are requiredto pay premium. SSNIT contributors do not pay premiums, nor do enrollees under the age of eighteen (18) orover the age of seventy (70) as well as indigent people are also exempted from premium payments.ClaimClaims management is a vital component of NHIS operations. On average, National Health Insurance Authority(NHIA) processes two million four hundred thousand (2,400.000) claims each month. For example, in 2014,claims expenses accounted for seventy seven percent (77%) of NHIS expenditure composition. Most claimsare submitted via paper forms, only eight percent (8%) are submitted electronically via other NHIS applications.Once providers submit their claims, the NHIA subjects them to a five step process: fulfillment, vetting, dataentry, vetting-report generation, and payment request initiation. A typical vetting-report include: informationon the total amount deducted for a given batch of claims from each facility. However, some providers havecomplained that these reports do not include specific information on individual calms.A recent World Bank study of the Ghana National Health Insurance Scheme revealed that claims expendituresvary significantly between individual facilities, even those of the same types. Per-claim expenditures foroutpatient services at primary hospitals ranges from eighteen Ghana cedi (GHc18) to hundred and twelve Ghanacedi (GHc112), a sixfold difference. The median claim value for primary hospitals is twenty four Ghana cedi(GHc24), and per-claim expenditures at the top five hospitals is at least fifty (50) higher than the median. Asimilar but less drastic pattern is observed for inpatient services, per-claim expenditures which range from onehundred and twenty-one Ghana cedi (GHc121) to Two hundred and sixty-two Ghana cedi (GHc262) (WorldBank, 2017).NHIA’s existing claims-vetting system is not properly equipped to identify abnormal behavior among servicesproviders. Claims offer a wealth of information on expenditure patterns, but most of the data captured by theNHIA are not analyzed. A number of reasons account for this phenomenon. First, existing data are not availablein a format conductive to analysis. For example, analysis of more than three thousand (3000) individual claimsExcel files from the Volta region submitted in 2014 show these files are not consistently formatted, and termsare used inconsistently. Addressing these issues is a costly and time-consuming process. While the NHIA hasbeen working to develop standard templates, these issues remain widespread in all regions. Second, the datacaptured by the current system are insufficient to verify the accuracy of the specified GDRG or appropriatenessof the treatment. The NHIA requires facilities to submit a claims summary that includes the patient’smembership identification number, GDRG, diagnosis, facility name, visit date, total cost, medicine and servicescost. However, only one diagnosis is included for each claim, and no information on prescription drugs isincluded. Claims also lack information on patients’ health status, which make it difficult for NHIS to determinewhether the diagnosis and GDRG coding were accurate and whether the treatment was appropriate. Third,claims data are not integrated with other databases. Consequently, these data cannot be automatically cross?referenced against the membership database, the database of facility characteristics or the overall health management information system. The information can be compared manually with special efforts, but this isnot a routine practice for the NHIA.Claims processing by NHIA is labor-intensive and inefficient. Claims are vetted on an individual basis. Mostclaims are evaluated manually, given the relatively small share that are electronically submitted. The NHIAexpends a staggering one thousand two (1,200) to four thousand eight hundred (4,800) staff weeks vetting, eachmonth’s claims, and maintaining this schedule requires hundreds of staff members. The NHIA has about onehundred and fifty (150) NHIA district offices and four (4) NHIA claims processing centers.Provider PaymentThe NHIS payment system does not promote cost-consciousness among service providers and encourageoversupply of services. Because health care facilities typically rely on the NHIS reimbursement to recover theiroperating expenses, they have no incentive to be efficient in claims expenditure. Furthermore, NHIS reimbursesprivate facilities at higher rates, while public facilities appear to be underutilized. The wage bill for the publichealth workers reached one billion five hundred million (GHc1.5 b) in 2014, but the available data indicate thatpublicly financed health care workers only see an average of 2 -2.9 outpatients per working day. Meanwhile, alarge share of NHIS Claims expenditures flows to private facilitatesPrevious claims-expenditure reviews have shown that some service providers exhibit abnormal behavior thatmay indicated fraud or abuse and that warrants additional scrutiny. Private facilities, which tend to be high-costproviders, are more likely that other facilities to submit incomplete claims information. Furthermore, amongprivate clinics that submit claims without GDRG information, fourty two (42) percent also lack diagnosisinformation, making it impossible to determine whether the GDRG is appropriate and these claims expenditureare eligible for reimbursement.Under the NHIS, providers were initially paid only on a fee-for-service (FFS) basis, but over time the paymentsystem evolved to encompass Ghana-diagnosis-related-groups (GDRG) and capitation. As FFS payments canincentivize an oversupply of services, GDRG and capitation payments were introduced to contain costs. Whilethe capitation payments are used for outpatient primary care in some regions of Ghana, GDRG are used for allinpatient care, all outpatient care in non-capitation regions, and outpatient care in capitation regions.Pharmaceutical costs are still reimbursed to providers on an FFS basis, which reflects predetermined tariffs andquantities of drugs submitted by providers.But there are limited opportunities for the NHIS members to provide feedback on their experiences. Aftermembers visit health care facilities, claims are submitted under their names by facilities, but there is nointeraction between members and NHIA. There is no standard mechanism for their NHIA to confirm receipt ofservices, service quality, payment problems or any other issues encountered by the membersService providersPrivate health care providers received higher GDRG tariffs and capitation rates to compensate for the lack ofpublic funding. Public providers (including Christian Health Association of Ghana (CHAG-facilities) receivefunding from MoH, whereas private providers do not receive it. Consequently, tariff rates differ significantlyby facility type and ownership. For example, the reimbursable cost of a general consultant for an adult patientis 76 percent higher for private primary hospital and 48 percent higher for a private clinic than it is for a public primary hospital.NHIA Board Meeting: Enhancing expenditure management at the NHISThe NHIA’s electronic claims-processing system should be expanded and redefined. The information providedby this system is significantly better than the summary data submitted in Excel files. However, the system coversonly eight percent (8%) of total claims. Moreover, only the submission stage is electronic, and the vettingprocess remains manual. In addition, data on the NHIA server can only be accessed by special request. Anenhanced electronic claims processing system should have increased capacity, algorithms for automated vetting,and linkages to other public health databases. Developing systems to identify and track patients could improvethe efficiency of claims expenditures and reduce errors and abuse.Source: Excerpts from National Health Insurance Scheme Report, 2017 (Credit to the World Bank Group)Required:1. Identify, analyse (using power/interest) and attitudes of stakeholders. Note that there can be morestakeholders than mentioned above. (6 marks)2. Represent the current state described above with models and the IT structure. (3 marks)3. What would the future state look like? Please use the same models as with the current state analysisand consider the constraints or the restrictions that may apply. (6 marks)4. What alternative solutions can you identify given the information above (and perhaps with makingreasonable assumptions)? (6 marks)5. Based on your digital solution, identify and list the functional requirements and if there are anytransitional requirements (12 marks