Hss Review Presentation 16th Oct

8/2/2019 Hss Review Presentation 16th Oct

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HAWA MEMORIAL SAVIOUR HOSPITAL

A PROGRESS REPORT ON THE HSSIMPLEMENTATION PROGRAM( NHIS )

BY

PETER DUAHBPHARM, MPSGH, IEMBA-healthcare mgt


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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


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INTRO CONT.The management of HMSH, intends t0 improve theefficiency of its health insurance claims management

to minimize revenue leakages due to errors inprocessed claims and to avert the issue of untimelysubmission and reduce deductions.


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Reasons for deductions / rejectionsy 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 andtreatment.


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Overall Objective

y To ensure that all forms of deductions and rejectionsare eliminated and to submit processed claims at mosttwo weeks of the ensuing month through the following

programs and actions.

y System blocks: Health technology

Health Information

Human resource for health

Leadership & Governance


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Health Technology

y Objective: To procure 3 computers by the end of June2011 for claims processing

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

y Activity: procure 3 desktop computers for claimsprocessing by June 2011

y Level of implementation: 9 computers & accessorieswere procured in October;

y Budget approved: GHC3,600.00

yAmount spent: GHC13,000.00


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Health Informationy Objective: To acquire claims processing software by

end of June 2011

y Indicator: Error free claims; Timely submissiony 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 institutiony Budget approved: 4650.00

yAmount Spent:GhC9650.69


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Human Resource for HealthObjectives 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 Indicator:Error free claims; Timely submission

y Measure: rejection rate; Submission deadline

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

y Level of implementation:

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


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Leader & GovernanceObjectives 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 2011y To develop SOPs 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 2011y SOPs developed


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SOPs

y To monitor the progress of work of the insurance unit ondaily basis(Finance Manager)

y Work is structured such that the days OPD attendances isworked on the preceding day

y In-patient claims are also collected & processed onMondays, Wednesdays and Fridays

yVetting committee members were to initiate vetting at theirvarious places of work

y Regular vetting committee meeting on Saturdays &Sundays


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Challengesy Reluctance on the part of MHIS to give breakdown on

the itemized cost of adjustments and rejections made.

yExtra finance committed to the program bymanagement has over stretched its overburdenedbudget

y Resistance to change at the start of the program


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INDICATOR JAN FEB MARCH APRIL MAY JUNE JULY

1.No. of

Claims

submitted

2649 2477 3519 3447 3141 3102 3733

2.No ofrejected

claims

6 15 11 11 1 2 0

3. No. Of

claims

Adjusted

150 124 185 174 613 37 21

4. Date of

submission

11/02/2011 8/03/2011 18/04/2011 16/05/2011 9/06/2011 11/07/2011 8/08/2011

5. Submission

deadline met

YES YES NO NO YES YES YES

Impact


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Success factorsy Management has been committed to the program.

yCoordination of the various units

y Regular interactions with NHIA officers on issuespertaining to claims management

y Regular feedback from NHIA officers on claimprocessing report


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RecommendationFunds should be sourced to do more of these programs

Unexpected Results: May 2011 adjustments


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Hss Review Presentation 16th Oct

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