The National Health Insurance Authority (NHIA) has reduced its indebtedness to service providers to only November and December 2023, as claims for January 2024 are now coming in to be vetted. 

For the past two years especially, the NHIA has made monthly claims payments to credentialled healthcare service providers whose submissions have been investigated and approved.

The most recent payments were made on February 13, 2024, with a sum GH¢130.24 million paid to 4,850 Mission, Public, Private, and Quasi-Public healthcare providers nationwide largely for claims submitted for the month of October 2023. Per the design of the scheme and agreed arrangements with healthcare providers, the NHIA said it should take about 90 days to receive, vet, and pay claims. 

Sunshine Policy

The NHIA said the introduction of the “Sunshine Policy” last March, has deepened accountability, social auditing, and transparency with regards to claims paid monthly.

Through the Sunshine Policy, it pointed out that all claims paid are published on the NHIS home page, https://nhis.gov.gh/payments, to update healthcare facilities and all other stakeholders.

It is therefore set to attain 100% electronic claims management by the end of this first quarter, allowing facilities to submit their claims electronically through the Claim-IT platform, whilst it also vets electronically and pays thereby creating efficiency in the process to reduce fraud and abuse.  

World Bank Support

A recent facility signed with the World Bank Group made available $27.7 million to the NHIA, to increase the National Health Insurance Scheme (NHIS) annual active membership, and as well facilitate claims processing and payments for primary healthcare providers.

The funding is allocated based on the Disbursement Linked Result (DLR) which is a set of targets to be achieved to access the funds which includes expanding the number of active members of the Scheme and digitizing the claims management process to enable the prompt payment of claims within a stipulated time.  

Caution on Illegal Payments 

In as much as the Authority has been successful in reducing the claims payments backlog to acceptable thresholds, it said there are still some credentialled service providers charging NHIS members for services covered by the Scheme.

In January 2024, the NHIA Governing Board and Executive Management served notice to suspend some 81 identified credentialed health facilities involved in such unauthorised charges ‘Copayments’.

Such practice, it said, is a clear violation of Section 35(1) of Act 852 and point 16.0 on "forbidden conduct" in the Master Provider Service Agreement.

Per the NHIS Act 852, Sections 35(1) and (2), the Authority is to ensure that the approved medicine list and tariffs are adhered to by the credentialed health service providers.

A further directive was issued in February 2024 notifying healthcare providers of the NHIA’s intention to enforce clause 15 of its contract with them which allows the Authority to make deductions from claims submitted as a Return of Payment for Services otherwise covered under the Scheme but charged to members. All such monies will be refunded to the aggrieved members after investigations are conducted.

The NHIA concluded that it is working to reduce Ghana’s NHIS Policy’s unintended out-of-pocket payments as this could lead to catastrophic health expenditures, especially for the poor and vulnerable.